Healthcare Provider Details

I. General information

NPI: 1053309518
Provider Name (Legal Business Name): WILSON TOBIN INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/10/2005
Last Update Date: 12/04/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 ILLINOIS ST BOX 571
SIDNEY NE
69162-1646
US

IV. Provider business mailing address

1000 ILLINOIS ST BOX 571
SIDNEY NE
69162-1646
US

V. Phone/Fax

Practice location:
  • Phone: 308-254-4553
  • Fax: 308-254-4554
Mailing address:
  • Phone: 308-254-4553
  • Fax: 308-254-4554

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number8014
License Number StateNE

VIII. Authorized Official

Name: MR. GERALD H BERLAGE
Title or Position: OWNER PHARMACIST
Credential: PHARMACIST
Phone: 308-254-4553