Provider Demographics
NPI:1891078887
Name:WIDMAN, DALE WILLIAM
Entity Type:Individual
Prefix:
First Name:DALE
Middle Name:WILLIAM
Last Name:WIDMAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:124 W VOTAW ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:IN
Mailing Address - Zip Code:47371-1143
Mailing Address - Country:US
Mailing Address - Phone:260-726-2049
Mailing Address - Fax:260-726-7675
Practice Address - Street 1:124 W VOTAW ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:IN
Practice Address - Zip Code:47371-1143
Practice Address - Country:US
Practice Address - Phone:260-726-2049
Practice Address - Fax:260-726-7675
Is Sole Proprietor?:No
Enumeration Date:2011-09-26
Last Update Date:2011-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26091614A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist