Provider Demographics
NPI:1003396060
Name:NERDERMAN, PENNY JEAN GEHRS
Entity Type:Individual
Prefix:
First Name:PENNY
Middle Name:JEAN GEHRS
Last Name:NERDERMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6286 WOODWIND CT
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:OH
Mailing Address - Zip Code:45044-8864
Mailing Address - Country:US
Mailing Address - Phone:513-571-3681
Mailing Address - Fax:
Practice Address - Street 1:75 W CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:CAMDEN
Practice Address - State:OH
Practice Address - Zip Code:45311-1007
Practice Address - Country:US
Practice Address - Phone:513-571-3681
Practice Address - Fax:937-452-3957
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-20
Last Update Date:2021-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03120595183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH03120595OtherPHARMACIST LICENSE