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General NPI Number Information
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NPI Number | 1235761545
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Entity Type | Individual
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Provider Name | GAGE WIDENER
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Gender | Male
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Dates
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Enumeration Date | 02/05/2020
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Last Update Date | 02/05/2020
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Provider Practice Location Address
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Address Line | 226 E PERKINS AVE
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City | SANDUSKY
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State | OH
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Zip | 44870-4905
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Country | US
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Telephone | 419-239-2624
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Fax |
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Provider Business Mailing Address
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Address Line | 1155 JACKSON ST
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City | VERMILION
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State | OH
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Zip | 44089-1073
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Country | US
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Telephone | 440-984-1078
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1835P0018X
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Taxonomy Name | Pharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
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License Number | 03438706
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License Number State | OH
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