Healthcare Provider Details

I. General information

NPI: 1063089050
Provider Name (Legal Business Name): WAHOO MAN LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/08/2021
Last Update Date: 06/08/2021
Certification Date: 06/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

526 N LINDEN ST
WAHOO NE
68066-1961
US

IV. Provider business mailing address

PO BOX 437
NORTH BEND NE
68649-0437
US

V. Phone/Fax

Practice location:
  • Phone: 402-443-4167
  • Fax:
Mailing address:
  • Phone: 402-652-3217
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code3336S0011X
TaxonomySpecialty Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: JED LEWIS
Title or Position: VICE PRESIDENT
Credential: PHARMD
Phone: 402-652-3217