Healthcare Provider Details

I. General information

NPI: 1629355508
Provider Name (Legal Business Name): BRENT WAYNE BOLLWITT PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/07/2011
Last Update Date: 06/23/2026
Certification Date: 06/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2201 N BROADWELL AVE
GRAND ISLAND NE
68803-2153
US

IV. Provider business mailing address

4171 NEW MEXICO AVE
GRAND ISLAND NE
68803-1057
US

V. Phone/Fax

Practice location:
  • Phone: 186-658-0181
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License Number13447
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: