Provider Demographics
NPI:1619564697
Name:WILSON, COLTON JOE
Entity Type:Individual
Prefix:
First Name:COLTON
Middle Name:JOE
Last Name:WILSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:514 E KILDARE DR
Mailing Address - Street 2:
Mailing Address - City:ONEILL
Mailing Address - State:NE
Mailing Address - Zip Code:68763-1142
Mailing Address - Country:US
Mailing Address - Phone:402-217-4647
Mailing Address - Fax:
Practice Address - Street 1:317 E DOUGLAS ST
Practice Address - Street 2:
Practice Address - City:ONEILL
Practice Address - State:NE
Practice Address - Zip Code:68763-1829
Practice Address - Country:US
Practice Address - Phone:402-336-2660
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-24
Last Update Date:2020-12-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE16205183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist