Healthcare Provider Details

I. General information

NPI: 1619147501
Provider Name (Legal Business Name): VICTORIA ANNE WEIDEMAN PHARM.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/06/2008
Last Update Date: 03/06/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5114 PALMETTO DR
FORT PIERCE FL
34982-7442
US

IV. Provider business mailing address

800 VIRGINIA AVE SUITE 31
FORT PIERCE FL
34982-5829
US

V. Phone/Fax

Practice location:
  • Phone: 772-468-0074
  • Fax:
Mailing address:
  • Phone: 772-468-0074
  • Fax: 772-468-2047

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberPS28684
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code1835N1003X
TaxonomyNutrition Support Pharmacist
License NumberPS28684
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: