Provider Demographics
NPI:1053309518
Name:WILSON TOBIN INC
Entity Type:Organization
Organization Name:WILSON TOBIN INC
Other - Org Name:WILSON TOBIN PHARMACY
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER PHARMACIST
Authorized Official - Prefix:MR
Authorized Official - First Name:GERALD
Authorized Official - Middle Name:H
Authorized Official - Last Name:BERLAGE
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMACIST
Authorized Official - Phone:308-254-4553
Mailing Address - Street 1:1000 ILLINOIS ST
Mailing Address - Street 2:BOX 571
Mailing Address - City:SIDNEY
Mailing Address - State:NE
Mailing Address - Zip Code:69162-1646
Mailing Address - Country:US
Mailing Address - Phone:308-254-4553
Mailing Address - Fax:308-254-4554
Practice Address - Street 1:1000 ILLINOIS ST
Practice Address - Street 2:BOX 571
Practice Address - City:SIDNEY
Practice Address - State:NE
Practice Address - Zip Code:69162-1646
Practice Address - Country:US
Practice Address - Phone:308-254-4553
Practice Address - Fax:308-254-4554
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-10
Last Update Date:2007-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE8014183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE00025207500Medicaid
0267360001Medicare NSC