Provider Demographics
NPI:1740532027
Name:WIDAMAN, KAREN A (RPH)
Entity type:Individual
Prefix:
First Name:KAREN
Middle Name:A
Last Name:WIDAMAN
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 SOUTHFIELD RD
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71105-3702
Mailing Address - Country:US
Mailing Address - Phone:318-861-2431
Mailing Address - Fax:318-861-4445
Practice Address - Street 1:105 SOUTHFIELD RD
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71105-3702
Practice Address - Country:US
Practice Address - Phone:318-861-2431
Practice Address - Fax:318-861-4445
Is Sole Proprietor?:No
Enumeration Date:2012-10-10
Last Update Date:2012-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA15851183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist