Provider Demographics
NPI:1073594917
Name:WIDAJAT, FIFI (RPH)
Entity Type:Individual
Prefix:MISS
First Name:FIFI
Middle Name:
Last Name:WIDAJAT
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 1:1253 FAREHARM DR
Mailing Address - Street 2:
Mailing Address - City:NEW ALBANY
Mailing Address - State:OH
Mailing Address - Zip Code:43054-9239
Mailing Address - Country:US
Mailing Address - Phone:614-506-3935
Mailing Address - Fax:
Practice Address - Street 1:1365 STONERIDGE DR
Practice Address - Street 2:KROGER PHARMACY N-871
Practice Address - City:GAHANNA
Practice Address - State:OH
Practice Address - Zip Code:43230-8701
Practice Address - Country:US
Practice Address - Phone:614-418-1529
Practice Address - Fax:614-418-1531
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03-2-23466183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist