Provider Demographics
NPI:1417074220
Name:WEIDMAN, MADONNA M (RPH,CDM)
Entity Type:Individual
Prefix:MRS
First Name:MADONNA
Middle Name:M
Last Name:WEIDMAN
Suffix:
Gender:F
Credentials:RPH,CDM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15321 PHEASANT DR
Mailing Address - Street 2:
Mailing Address - City:COUNCIL BLUFFS
Mailing Address - State:IA
Mailing Address - Zip Code:51503-5818
Mailing Address - Country:US
Mailing Address - Phone:712-322-7573
Mailing Address - Fax:
Practice Address - Street 1:1706 N 16TH ST
Practice Address - Street 2:
Practice Address - City:COUNCIL BLUFFS
Practice Address - State:IA
Practice Address - Zip Code:51501-0121
Practice Address - Country:US
Practice Address - Phone:712-322-3111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA15760183500000X
NE11934183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist