Provider Demographics
NPI:1861785560
Name:WISE, KENNETH EDGAR (PHARM D)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:EDGAR
Last Name:WISE
Suffix:
Gender:M
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:708 SW 4TH AVE
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32601-6427
Mailing Address - Country:US
Mailing Address - Phone:352-376-8286
Mailing Address - Fax:
Practice Address - Street 1:708 SW 4TH AVE
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32601-6427
Practice Address - Country:US
Practice Address - Phone:352-376-8286
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-27
Last Update Date:2019-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS35868183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist