Provider Demographics
NPI:1073135422
Name:WIEDERIN, ELIZABETH ANN (PHARMD)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:ANN
Last Name:WIEDERIN
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:989200 NEBRASKA MEDICAL CTR
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68198-9200
Mailing Address - Country:US
Mailing Address - Phone:402-552-7999
Mailing Address - Fax:
Practice Address - Street 1:989200 NEBRASKA MEDICAL CTR
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68198-9200
Practice Address - Country:US
Practice Address - Phone:402-552-7999
Practice Address - Fax:402-552-7792
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-08
Last Update Date:2020-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA22288183500000X
TX60330183500000X
NE14603183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist