Provider Demographics
NPI:1053917401
Name:WENDEROTH, ANDREA (RPH)
Entity type:Individual
Prefix:
First Name:ANDREA
Middle Name:
Last Name:WENDEROTH
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2668 E CIANA CT
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47401-8358
Mailing Address - Country:US
Mailing Address - Phone:812-824-7732
Mailing Address - Fax:
Practice Address - Street 1:1000 N COLLEGE AVE
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47404-3550
Practice Address - Country:US
Practice Address - Phone:812-339-2233
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-10
Last Update Date:2020-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26018364A208U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208U00000XAllopathic & Osteopathic PhysiciansClinical Pharmacology
Provider Identifiers
StateIdentifier IDID TypeIssuer
INSHANER54Medicaid