Provider Demographics
NPI:1043591092
Name:WILTRAKIS, LYNN G (RPH)
Entity Type:Individual
Prefix:MR
First Name:LYNN
Middle Name:G
Last Name:WILTRAKIS
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12115 W 95TH PL
Mailing Address - Street 2:
Mailing Address - City:SAINT JOHN
Mailing Address - State:IN
Mailing Address - Zip Code:46373-9537
Mailing Address - Country:US
Mailing Address - Phone:219-365-3135
Mailing Address - Fax:
Practice Address - Street 1:407 W GLEN PARK AVE
Practice Address - Street 2:
Practice Address - City:GRIFFITH
Practice Address - State:IN
Practice Address - Zip Code:46319-1511
Practice Address - Country:US
Practice Address - Phone:219-924-2703
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-05
Last Update Date:2011-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26016285A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist