Provider Demographics
NPI:1508080052
Name:WIDMANN, THERESA A (RPH)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:A
Last Name:WIDMANN
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 BRANCH ST
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:NJ
Mailing Address - Zip Code:08055-2702
Mailing Address - Country:US
Mailing Address - Phone:609-654-0341
Mailing Address - Fax:
Practice Address - Street 1:1 MEDFORD LEAS
Practice Address - Street 2:PHARMACY
Practice Address - City:MEDFORD
Practice Address - State:NJ
Practice Address - Zip Code:08055-2254
Practice Address - Country:US
Practice Address - Phone:609-654-3269
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RI01993500183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist