Healthcare Provider Details

I. General information

NPI: 1790221539
Provider Name (Legal Business Name): JACQUELYN WOIDERSKI PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/18/2017
Last Update Date: 01/18/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

127 N MAIN ST
CHEBOYGAN MI
49721-1637
US

IV. Provider business mailing address

127 N MAIN ST
CHEBOYGAN MI
49721-1637
US

V. Phone/Fax

Practice location:
  • Phone: 231-627-9949
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number5302040635
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number18009-40
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: