Provider Demographics
NPI:1962538801
Name:WILT, SHAWN CUMMINGS
Entity type:Individual
Prefix:MR
First Name:SHAWN
Middle Name:CUMMINGS
Last Name:WILT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2624 DRUMMOND RD
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43606-3045
Mailing Address - Country:US
Mailing Address - Phone:419-534-5587
Mailing Address - Fax:
Practice Address - Street 1:7504 WEST CENTRAL AVENUE
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43617
Practice Address - Country:US
Practice Address - Phone:419-841-8525
Practice Address - Fax:419-841-8620
Is Sole Proprietor?:No
Enumeration Date:2007-02-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03-1-22445183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist