Provider Demographics
NPI:1013205335
Name:EBERHARDT, IDONA JEAN JELEN (RPH)
Entity Type:Individual
Prefix:MRS
First Name:IDONA
Middle Name:JEAN JELEN
Last Name:EBERHARDT
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1043 DEXTER MOUNTAIN RD
Mailing Address - Street 2:
Mailing Address - City:GLOVER
Mailing Address - State:VT
Mailing Address - Zip Code:05839-9665
Mailing Address - Country:US
Mailing Address - Phone:802-525-3152
Mailing Address - Fax:
Practice Address - Street 1:1043 DEXTER MOUNTAIN RD
Practice Address - Street 2:
Practice Address - City:GLOVER
Practice Address - State:VT
Practice Address - Zip Code:05839-9665
Practice Address - Country:US
Practice Address - Phone:802-525-3152
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-20
Last Update Date:2011-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VTVT3619183500000X
FLPS26840183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist