Provider Demographics
NPI:1316080914
Name:WIEDERKEHR, MARTIN (BS PHARM)
Entity type:Individual
Prefix:MR
First Name:MARTIN
Middle Name:
Last Name:WIEDERKEHR
Suffix:
Gender:M
Credentials:BS PHARM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6389 BRAVA WAY
Mailing Address - Street 2:
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33433-8236
Mailing Address - Country:US
Mailing Address - Phone:561-750-7443
Mailing Address - Fax:707-264-8619
Practice Address - Street 1:6389 BRAVA WAY
Practice Address - Street 2:
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33433-8236
Practice Address - Country:US
Practice Address - Phone:561-750-7443
Practice Address - Fax:707-264-8619
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL7924183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist