Healthcare Provider Details

I. General information

NPI: 1609562131
Provider Name (Legal Business Name): TED WIEDMANN PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/17/2023
Last Update Date: 08/21/2023
Certification Date: 08/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 S INDUSTRY WAY STE 240
MERIDIAN ID
83642-3559
US

IV. Provider business mailing address

1863 N ARONMINK WAY
MERIDIAN ID
83646-1162
US

V. Phone/Fax

Practice location:
  • Phone: 208-884-0669
  • Fax: 208-955-3291
Mailing address:
  • Phone: 661-428-7082
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number30904
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberP9212
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: