Healthcare Provider Details

I. General information

NPI: 1174202691
Provider Name (Legal Business Name): MARCELA WIETSTRUCK HEISS PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2023
Last Update Date: 10/29/2024
Certification Date: 10/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 E IDAHO ST
BOISE ID
83712-6267
US

IV. Provider business mailing address

100 E IDAHO ST
BOISE ID
83712-6267
US

V. Phone/Fax

Practice location:
  • Phone: 720-800-2851
  • Fax:
Mailing address:
  • Phone: 720-800-2851
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835X0200X
TaxonomyOncology Pharmacist
License NumberP10126
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: