Healthcare Provider Details

I. General information

NPI: 1033133947
Provider Name (Legal Business Name): DOUGLAS ERIC HEIDBREDER R.PH.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/26/2006
Last Update Date: 03/05/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 W. MAIN STREET
ADDISON MI
49220
US

IV. Provider business mailing address

P.O. BOX 349 100 W. MAIN STREET
ADDISON MI
49220
US

V. Phone/Fax

Practice location:
  • Phone: 517-547-6686
  • Fax: 517-547-3401
Mailing address:
  • Phone: 517-547-6686
  • Fax: 517-547-3401

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number5302026194
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: