Provider Demographics
NPI:1518491513
Name:VIDIS, JERRY SHERWIN (RPH, MS)
Entity Type:Individual
Prefix:MR
First Name:JERRY
Middle Name:SHERWIN
Last Name:VIDIS
Suffix:
Gender:M
Credentials:RPH, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:41092 NORTHWIND DR
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:MI
Mailing Address - Zip Code:48188-3115
Mailing Address - Country:US
Mailing Address - Phone:734-397-2783
Mailing Address - Fax:
Practice Address - Street 1:41092 NORTHWIND DR
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:MI
Practice Address - Zip Code:48188-3115
Practice Address - Country:US
Practice Address - Phone:734-397-2783
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-17
Last Update Date:2020-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302022445183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist