Provider Demographics
NPI:1184619330
Name:WILT, JACKIE MARIE (PHARMD)
Entity type:Individual
Prefix:
First Name:JACKIE
Middle Name:MARIE
Last Name:WILT
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7079 610TH ST
Mailing Address - Street 2:
Mailing Address - City:WHEATON
Mailing Address - State:MN
Mailing Address - Zip Code:56296-5095
Mailing Address - Country:US
Mailing Address - Phone:320-563-8500
Mailing Address - Fax:
Practice Address - Street 1:400 E 1ST ST
Practice Address - Street 2:
Practice Address - City:MORRIS
Practice Address - State:MN
Practice Address - Zip Code:56267-1408
Practice Address - Country:US
Practice Address - Phone:320-589-7679
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN116302-7183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist