Provider Demographics
NPI:1497022560
Name:WIGDAHL, NATHAN JOSEPH (PHARMD)
Entity Type:Individual
Prefix:
First Name:NATHAN
Middle Name:JOSEPH
Last Name:WIGDAHL
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 1:3005 LAKE ST
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68111-3780
Mailing Address - Country:US
Mailing Address - Phone:402-451-7201
Mailing Address - Fax:
Practice Address - Street 1:3005 LAKE ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68111-3780
Practice Address - Country:US
Practice Address - Phone:402-451-7201
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-11-17
Last Update Date:2011-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE2400183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist