Provider Demographics
NPI:1609562131
Name:WIEDMANN, TED (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:TED
Middle Name:
Last Name:WIEDMANN
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 1:1863 N ARONMINK WAY
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83646-1162
Mailing Address - Country:US
Mailing Address - Phone:661-428-7082
Mailing Address - Fax:
Practice Address - Street 1:800 S INDUSTRY WAY STE 240
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-3559
Practice Address - Country:US
Practice Address - Phone:208-884-0669
Practice Address - Fax:208-955-3291
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-17
Last Update Date:2023-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA30904183500000X
IDP9212183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist