Provider Demographics
NPI:1578230421
Name:WIEDEMANN, THOMAS WARREN JR (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:WARREN
Last Name:WIEDEMANN
Suffix:JR
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2094 ALBANY POST RD
Mailing Address - Street 2:
Mailing Address - City:MONTROSE
Mailing Address - State:NY
Mailing Address - Zip Code:10548-1454
Mailing Address - Country:US
Mailing Address - Phone:914-737-4400
Mailing Address - Fax:
Practice Address - Street 1:2094 ALBANY POST RD
Practice Address - Street 2:
Practice Address - City:MONTROSE
Practice Address - State:NY
Practice Address - Zip Code:10548-1454
Practice Address - Country:US
Practice Address - Phone:914-737-4400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-27
Last Update Date:2021-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RI04131000183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist