Provider Demographics
NPI:1114415742
Name:TEDJO, ADRIENNE BERNADETTE
Entity Type:Individual
Prefix:
First Name:ADRIENNE
Middle Name:BERNADETTE
Last Name:TEDJO
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 1:1606 S 72ND ST
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68124-1600
Mailing Address - Country:US
Mailing Address - Phone:402-393-9571
Mailing Address - Fax:
Practice Address - Street 1:1606 S 72ND ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68124-1600
Practice Address - Country:US
Practice Address - Phone:402-393-9571
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-30
Last Update Date:2018-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE15841183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist