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General NPI Number Information
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NPI Number | 1417074220
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Entity Type | Individual
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Provider Name | MADONNA M WEIDMAN RPH,CDM
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Gender | Female
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Dates
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Enumeration Date | 03/25/2007
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 1706 N 16TH ST
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City | COUNCIL BLUFFS
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State | IA
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Zip | 51501-0121
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Country | US
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Telephone | 712-322-3111
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Fax |
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Provider Business Mailing Address
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Address Line | 15321 PHEASANT DR
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City | COUNCIL BLUFFS
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State | IA
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Zip | 51503-5818
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Country | US
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Telephone | 712-322-7573
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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 | 183500000X
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Taxonomy Name | Pharmacist
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License Number | 15760
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License Number State | IA
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Taxonomy #2
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Taxonomy Code | 183500000X
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Taxonomy Name | Pharmacist
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License Number | 11934
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License Number State | NE
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