1568463628 NPI number — DR. THEODORE D HEIERMAN PHARM.D.

Table of content: DR. THEODORE D HEIERMAN PHARM.D. (NPI 1568463628)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568463628 NPI number — DR. THEODORE D HEIERMAN PHARM.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HEIERMAN
Provider First Name:
THEODORE
Provider Middle Name:
D
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PHARM.D.
Provider Gender Code:
M

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:
1568463628
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4702 CREW CIR
Provider Second Line Business Mailing Address:
APT 12
Provider Business Mailing Address City Name:
MELBOURNE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32904-8445
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
321-434-1838
Provider Business Mailing Address Fax Number:
321-434-5211

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1350 S HICKORY ST
Provider Second Line Business Practice Location Address:
DEPT OF PHARMACY
Provider Business Practice Location Address City Name:
MELBOURNE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32901-3278
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
321-434-1838
Provider Business Practice Location Address Fax Number:
321-434-5211
Provider Enumeration Date:
08/10/2005

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:  PS 36609 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 1835P1200X , with the licence number: PS 36609 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .

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





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