MEDICARE: DR. THERESA M HEITZ PHARM D.

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	051291042	IL

General Provider Information

NPI Number	:	1124312319
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. THERESA M HEITZ PHARM D.

Provider Business Mailing Address
First Line	:	2555 SYCAMORE RD
Second Line	:
City	:	DEKALB
State	:	IL
Zip	:	60115-2051
Country	:	US
Telephone Number	:	815-787-6971
Fax Number	:	815-787-6971

Provider Business Practice Location Address
First Line	:	2555 SYCAMORE RD
Second Line	:
City	:	DEKALB
State	:	IL
Zip	:	60115-2051
Country	:	US
Telephone Number	:	815-787-6971
Fax Number	:	815-787-6971

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

Provider Enumeration Date	:	06/05/2011
Last Update Date	:	06/05/2011

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