Provider Demographics
NPI:1447347992
Name:WIDEMOND, ANNIE CLARA (CPHT)
Entity type:Individual
Prefix:MRS
First Name:ANNIE
Middle Name:CLARA
Last Name:WIDEMOND
Suffix:
Gender:F
Credentials:CPHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:507 GRISSHOLM ST
Mailing Address - Street 2:P. O. BOX 1192
Mailing Address - City:MACCLENNY
Mailing Address - State:FL
Mailing Address - Zip Code:32063-2613
Mailing Address - Country:US
Mailing Address - Phone:904-259-6785
Mailing Address - Fax:
Practice Address - Street 1:1436 STATE ROAD 121 SOUTH
Practice Address - Street 2:
Practice Address - City:MACCLENNY
Practice Address - State:FL
Practice Address - Zip Code:32063
Practice Address - Country:US
Practice Address - Phone:904-259-5868
Practice Address - Fax:904-259-5275
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL2901-0104-0756-923183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician