Provider Demographics
NPI:1629355508
Name:BOLLWITT, BRENT WAYNE (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:BRENT
Middle Name:WAYNE
Last Name:BOLLWITT
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 1:7045 S HARRISON HILLS DR
Mailing Address - Street 2:#301
Mailing Address - City:LA VISTA
Mailing Address - State:NE
Mailing Address - Zip Code:68128-7709
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2201 N BROADWELL AVE
Practice Address - Street 2:
Practice Address - City:GRAND ISLAND
Practice Address - State:NE
Practice Address - Zip Code:68803-2153
Practice Address - Country:US
Practice Address - Phone:186-658-0181
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-11-07
Last Update Date:2011-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE13447183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist