MEDICARE: DR. HEATHER PETRIE PHARMD, CPH

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	PS48532	FL

General Provider Information

NPI Number	:	1063833879
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. HEATHER PETRIE PHARMD, CPH

Provider Business Mailing Address
First Line	:	4175 S PIPKIN RD
Second Line	:	SUITE 208
City	:	LAKELAND
State	:	FL
Zip	:	33811-1699
Country	:	US
Telephone Number	:	863-577-1440
Fax Number	:	863-577-1444

Provider Business Practice Location Address
First Line	:	4175 S PIPKIN RD
Second Line	:	SUITE 208
City	:	LAKELAND
State	:	FL
Zip	:	33811-1699
Country	:	US
Telephone Number	:	863-577-1440
Fax Number	:	863-577-1444

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/20/2013
Last Update Date	:	12/20/2013

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