Provider Demographics
NPI:1235761545
Name:WIDENER, GAGE
Entity Type:Individual
Prefix:
First Name:GAGE
Middle Name:
Last Name:WIDENER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1155 JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:VERMILION
Mailing Address - State:OH
Mailing Address - Zip Code:44089-1073
Mailing Address - Country:US
Mailing Address - Phone:440-984-1078
Mailing Address - Fax:
Practice Address - Street 1:226 E PERKINS AVE
Practice Address - Street 2:
Practice Address - City:SANDUSKY
Practice Address - State:OH
Practice Address - Zip Code:44870-4905
Practice Address - Country:US
Practice Address - Phone:419-239-2624
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-05
Last Update Date:2020-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH034387061835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist