Provider Demographics
NPI:1205101599
Name:HERDRICH, JON DANIEL (RPH)
Entity type:Individual
Prefix:MR
First Name:JON
Middle Name:DANIEL
Last Name:HERDRICH
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 1:485 N ROLLING MEADOWS DR
Mailing Address - Street 2:
Mailing Address - City:FOND DU LAC
Mailing Address - State:WI
Mailing Address - Zip Code:54937-9784
Mailing Address - Country:US
Mailing Address - Phone:920-921-6759
Mailing Address - Fax:920-921-6759
Practice Address - Street 1:485 N ROLLING MEADOWS DR
Practice Address - Street 2:T0808
Practice Address - City:FOND DU LAC
Practice Address - State:WI
Practice Address - Zip Code:54937-9784
Practice Address - Country:US
Practice Address - Phone:920-921-6759
Practice Address - Fax:920-921-6759
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-20
Last Update Date:2012-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI11072-40183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist