Organization
WISDOM DRUG LLC
Active
Other names
Vandivort Drug
Organization subpart
No
Provider details
NPI number
Authorized official
TEEL RYAN WISDOM (OWNER/PHARMACIST IN CHARGE)
(573) 729-4114
Entity
Organization
Contact information
Practice address
117 W 4TH ST, SALEM, MO 65560-1255
(573) 729-4114
(573) 729-5353
Mailing address
117 W 4TH ST, SALEM, MO 65560-1255
(573) 729-4114
(573) 729-5353
Taxonomy
Speciality
Code
Description
License number
State
3336C0003X
Community/Retail Pharmacy
Primary
PS 004855
MO
3336L0003X
Long Term Care Pharmacy
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
600126916
—
MO
Enumeration date
06/15/2006
Last updated
02/14/2020
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