Provider Demographics
NPI:1184389850
Name:WEIDEMAN, RYAN MICHAEL
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:MICHAEL
Last Name:WEIDEMAN
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 1:5091 STEWART AVE APT 101
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45227-3672
Mailing Address - Country:US
Mailing Address - Phone:724-996-0950
Mailing Address - Fax:
Practice Address - Street 1:1915 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:OH
Practice Address - Zip Code:45044-4401
Practice Address - Country:US
Practice Address - Phone:513-420-2546
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-07
Last Update Date:2021-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03441278183500000X
PARP456101183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist