Provider Demographics
NPI:1164708699
Name:WEIDIG, OWEN T (RPH)
Entity Type:Individual
Prefix:MR
First Name:OWEN
Middle Name:T
Last Name:WEIDIG
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1617 10TH ST
Mailing Address - Street 2:
Mailing Address - City:PORT HURON
Mailing Address - State:MI
Mailing Address - Zip Code:48060-5844
Mailing Address - Country:US
Mailing Address - Phone:810-987-5083
Mailing Address - Fax:810-987-5317
Practice Address - Street 1:1215 24TH ST
Practice Address - Street 2:
Practice Address - City:PORT HURON
Practice Address - State:MI
Practice Address - Zip Code:48060-4812
Practice Address - Country:US
Practice Address - Phone:810-987-7155
Practice Address - Fax:810-987-4017
Is Sole Proprietor?:No
Enumeration Date:2011-10-28
Last Update Date:2020-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302410763183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist