Provider Demographics
NPI:1205376456
Name:WIDMYER, KATHLEEN (RPH)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:WIDMYER
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 1:700 W IRONWOOD DR STE 246
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-4473
Mailing Address - Country:US
Mailing Address - Phone:208-625-5688
Mailing Address - Fax:208-625-5687
Practice Address - Street 1:700 W IRONWOOD DR STE 246
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-4473
Practice Address - Country:US
Practice Address - Phone:208-625-5688
Practice Address - Fax:208-625-5687
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-06
Last Update Date:2017-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP50811835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist