Provider Demographics
NPI:1831116763
Name:WIGHTMAN PHARMACY INC
Entity type:Organization
Organization Name:WIGHTMAN PHARMACY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHARM
Authorized Official - Prefix:
Authorized Official - First Name:STEVE
Authorized Official - Middle Name:
Authorized Official - Last Name:WIGHTMAN
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:618-939-6218
Mailing Address - Street 1:127 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WATERLOO
Mailing Address - State:IL
Mailing Address - Zip Code:62298-1371
Mailing Address - Country:US
Mailing Address - Phone:618-939-6218
Mailing Address - Fax:618-939-4633
Practice Address - Street 1:127 S MAIN ST
Practice Address - Street 2:
Practice Address - City:WATERLOO
Practice Address - State:IL
Practice Address - Zip Code:62298-1371
Practice Address - Country:US
Practice Address - Phone:618-939-6218
Practice Address - Fax:618-939-4633
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-16
Last Update Date:2017-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
IL0540014713336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2016696OtherPK
0682590001Medicare NSC