Provider Demographics
NPI:1326617259
Name:WIEDMAN, JENNIE DIANNE
Entity Type:Individual
Prefix:
First Name:JENNIE
Middle Name:DIANNE
Last Name:WIEDMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6163 N WAYNE AVE
Mailing Address - Street 2:
Mailing Address - City:PENTWATER
Mailing Address - State:MI
Mailing Address - Zip Code:49449-8595
Mailing Address - Country:US
Mailing Address - Phone:231-301-9952
Mailing Address - Fax:
Practice Address - Street 1:1500 E SHERMAN BLVD
Practice Address - Street 2:
Practice Address - City:MUSKEGON
Practice Address - State:MI
Practice Address - Zip Code:49444-1849
Practice Address - Country:US
Practice Address - Phone:231-372-3632
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-24
Last Update Date:2021-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302413067183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist