Provider Demographics
NPI:1215954193
Name:WIGHTMAN, THOMAS S (RPH)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:S
Last Name:WIGHTMAN
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:414 LOUISE LN
Mailing Address - Street 2:
Mailing Address - City:WATERLOO
Mailing Address - State:IL
Mailing Address - Zip Code:62298-3283
Mailing Address - Country:US
Mailing Address - Phone:618-939-6033
Mailing Address - Fax:
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:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist