Provider Demographics
NPI:1578873022
Name:WIEDEMANN, JEFFREY DANA (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:DANA
Last Name:WIEDEMANN
Suffix:
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 1:1255 NE 48TH AVE
Mailing Address - Street 2:
Mailing Address - City:HILLSBORO
Mailing Address - State:OR
Mailing Address - Zip Code:97124-5008
Mailing Address - Country:US
Mailing Address - Phone:503-681-2828
Mailing Address - Fax:503-681-2825
Practice Address - Street 1:1255 NE 48TH AVE
Practice Address - Street 2:
Practice Address - City:HILLSBORO
Practice Address - State:OR
Practice Address - Zip Code:97124-5008
Practice Address - Country:US
Practice Address - Phone:503-681-2828
Practice Address - Fax:503-681-2825
Is Sole Proprietor?:No
Enumeration Date:2010-10-18
Last Update Date:2010-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR12276183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist