Provider Demographics
NPI:1063089050
Name:WAHOO MAN LLC
Entity type:Organization
Organization Name:WAHOO MAN LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JED
Authorized Official - Middle Name:
Authorized Official - Last Name:LEWIS
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:402-652-3217
Mailing Address - Street 1:PO BOX 437
Mailing Address - Street 2:
Mailing Address - City:NORTH BEND
Mailing Address - State:NE
Mailing Address - Zip Code:68649-0437
Mailing Address - Country:US
Mailing Address - Phone:402-652-3217
Mailing Address - Fax:
Practice Address - Street 1:526 N LINDEN ST
Practice Address - Street 2:
Practice Address - City:WAHOO
Practice Address - State:NE
Practice Address - Zip Code:68066-1961
Practice Address - Country:US
Practice Address - Phone:402-443-4167
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BP INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-06-08
Last Update Date:2021-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy