Provider Demographics
NPI:1427653310
Name:VIDERMAN, THOMAS
Entity type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:
Last Name:VIDERMAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2908 BOWDOIN PL
Mailing Address - Street 2:
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34207-5522
Mailing Address - Country:US
Mailing Address - Phone:386-315-1631
Mailing Address - Fax:
Practice Address - Street 1:105 S PEBBLE BEACH BLVD
Practice Address - Street 2:
Practice Address - City:SUN CITY CENTER
Practice Address - State:FL
Practice Address - Zip Code:33573-5791
Practice Address - Country:US
Practice Address - Phone:813-633-8082
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-01
Last Update Date:2020-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS51789183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist