Healthcare Provider Details

I. General information

NPI: 1417500992
Provider Name (Legal Business Name): HEATHER PORTER PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/23/2019
Last Update Date: 07/23/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10535 HOSPITAL WAY
MATHER CA
95655-4200
US

IV. Provider business mailing address

5257 MODDISON AVE
SACRAMENTO CA
95819-1612
US

V. Phone/Fax

Practice location:
  • Phone: 435-559-4114
  • Fax:
Mailing address:
  • Phone: 435-559-4114
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P1300X
TaxonomyPsychiatric Pharmacist
License NumberRPH-0016445
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: