Provider Demographics
NPI:1326233354
Name:WIEDERRICH, JEROME DONALD (RPH)
Entity Type:Individual
Prefix:MR
First Name:JEROME
Middle Name:DONALD
Last Name:WIEDERRICH
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 1:3000 S MINNESOTA AVE
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57105-5647
Mailing Address - Country:US
Mailing Address - Phone:605-334-8012
Mailing Address - Fax:605-334-7949
Practice Address - Street 1:3000 S MINNESOTA AVE
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57105-5647
Practice Address - Country:US
Practice Address - Phone:605-334-8012
Practice Address - Fax:605-334-7949
Is Sole Proprietor?:No
Enumeration Date:2007-09-12
Last Update Date:2007-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD4270183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist