1376845362 NPI number — HEATHER PEACOCK PHARMD

Table of content: HEATHER PEACOCK PHARMD (NPI 1376845362)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1376845362 NPI number — HEATHER PEACOCK PHARMD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PEACOCK
Provider First Name:
HEATHER
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PHARMD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1376845362
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/10/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1235 CLAYTON LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
COLUMBIA FALLS
Provider Business Mailing Address State Name:
MT
Provider Business Mailing Address Postal Code:
59912-4495
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
406-892-0299
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
20 FOUR MILE DR
Provider Second Line Business Practice Location Address:
SUITE 3
Provider Business Practice Location Address City Name:
KALISPELL
Provider Business Practice Location Address State Name:
MT
Provider Business Practice Location Address Postal Code:
59901-2632
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
406-752-0440
Provider Business Practice Location Address Fax Number:
406-752-0443
Provider Enumeration Date:
11/23/2010

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 183500000X , with the licence number:  6324 , registered in the state of MT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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