Provider Demographics
NPI:1225633852
Name:WILT, ANDRE (PHARMD)
Entity Type:Individual
Prefix:
First Name:ANDRE
Middle Name:
Last Name:WILT
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12927 REYNOLDS ST
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68142-1812
Mailing Address - Country:US
Mailing Address - Phone:609-751-4103
Mailing Address - Fax:
Practice Address - Street 1:1001 SOUTH ST
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68502-2251
Practice Address - Country:US
Practice Address - Phone:609-751-4103
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-01
Last Update Date:2020-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE16807183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist