Healthcare Provider Details

I. General information

NPI: 1396927539
Provider Name (Legal Business Name): CANDACE KAY HEARD RPH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/29/2007
Last Update Date: 11/29/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

240 TALLAPOOSA ST
BREMEN GA
30110
US

IV. Provider business mailing address

240 TALLAPOOSA ST
BREMEN GA
30110
US

V. Phone/Fax

Practice location:
  • Phone: 770-537-2386
  • Fax: 770-537-4418
Mailing address:
  • Phone: 770-537-2386
  • Fax: 770-537-4418

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number012397
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: