Provider Demographics
NPI:1578610549
Name:REDIGER, JOHN THOMAS (RPH)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:THOMAS
Last Name:REDIGER
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:724 S. EDDY
Mailing Address - Street 2:P.O BOX 1760
Mailing Address - City:PECOS
Mailing Address - State:TX
Mailing Address - Zip Code:79772-1760
Mailing Address - Country:US
Mailing Address - Phone:432-445-4916
Mailing Address - Fax:432-445-6085
Practice Address - Street 1:724 S EDDY ST
Practice Address - Street 2:
Practice Address - City:PECOS
Practice Address - State:TX
Practice Address - Zip Code:79772-3727
Practice Address - Country:US
Practice Address - Phone:432-445-4916
Practice Address - Fax:432-445-6085
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX12062183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX143040Medicaid