Provider Demographics
NPI:1275801581
Name:HEDTKE, ROGER WILLIAM
Entity Type:Individual
Prefix:
First Name:ROGER
Middle Name:WILLIAM
Last Name:HEDTKE
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 1:1218 W RIVER ST
Mailing Address - Street 2:
Mailing Address - City:MONTICELLO
Mailing Address - State:MN
Mailing Address - Zip Code:55362-8953
Mailing Address - Country:US
Mailing Address - Phone:763-295-4558
Mailing Address - Fax:763-271-3376
Practice Address - Street 1:135 EAST BROADWAY
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:MN
Practice Address - Zip Code:55362
Practice Address - Country:US
Practice Address - Phone:763-295-5890
Practice Address - Fax:763-271-3376
Is Sole Proprietor?:No
Enumeration Date:2011-12-01
Last Update Date:2011-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN112323183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist