Healthcare Provider Details

I. General information

NPI: 1760592562
Provider Name (Legal Business Name): PATRICK M HEYERDAHL R.PH.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/30/2006
Last Update Date: 05/09/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1801 HICKMAN RD
DES MOINES IA
50314-1548
US

IV. Provider business mailing address

1801 HICKMAN RD
DES MOINES IA
50314-1505
US

V. Phone/Fax

Practice location:
  • Phone: 515-282-2444
  • Fax:
Mailing address:
  • Phone: 515-282-2456
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number17765
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: