Healthcare Provider Details

I. General information

NPI: 1104341585
Provider Name (Legal Business Name): HEATHER L SUDIK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/07/2017
Last Update Date: 08/07/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21 CARDINAL DR
ORRINGTON ME
04474-3020
US

IV. Provider business mailing address

21 CARDINAL DR
ORRINGTON ME
04474-3020
US

V. Phone/Fax

Practice location:
  • Phone: 402-239-0762
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberPI28045
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: