Healthcare Provider Details

I. General information

NPI: 1275412751
Provider Name (Legal Business Name): WYATT KILE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/29/2025
Last Update Date: 08/29/2025
Certification Date: 08/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1710 W 2ND ST
GRAND ISLAND NE
68803-5409
US

IV. Provider business mailing address

4006 HUFF BLVD
GRAND ISLAND NE
68803
US

V. Phone/Fax

Practice location:
  • Phone: 308-384-4089
  • Fax:
Mailing address:
  • Phone: 402-746-0368
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number17898
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: