MEDICARE: TIM HEIRD DPH

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	13174	OK

General Provider Information

NPI Number	:	1891253043
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TIM HEIRD DPH

Provider Business Mailing Address
First Line	:	1910 N MAIN ST
Second Line	:
City	:	MIAMI
State	:	OK
Zip	:	74354-2132
Country	:	US
Telephone Number	:	918-542-4795
Fax Number	:	918-542-6019

Provider Business Practice Location Address
First Line	:	1910 N MAIN ST
Second Line	:
City	:	MIAMI
State	:	OK
Zip	:	74354-2132
Country	:	US
Telephone Number	:	918-542-4795
Fax Number	:	918-542-6019

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

Provider Enumeration Date	:	03/06/2019
Last Update Date	:	03/06/2019

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