Provider Demographics
NPI:1295182186
Name:WIDGER, JOHN
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:WIDGER
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 1:6140 NORTHWEST HWY
Mailing Address - Street 2:
Mailing Address - City:CRYSTAL LAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60014-7931
Mailing Address - Country:US
Mailing Address - Phone:815-356-8592
Mailing Address - Fax:815-356-8790
Practice Address - Street 1:6140 NORTHWEST HWY
Practice Address - Street 2:
Practice Address - City:CRYSTAL LAKE
Practice Address - State:IL
Practice Address - Zip Code:60014-7931
Practice Address - Country:US
Practice Address - Phone:815-356-8592
Practice Address - Fax:815-356-8790
Is Sole Proprietor?:No
Enumeration Date:2016-05-20
Last Update Date:2016-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051-038999183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist