Healthcare Provider Details

I. General information

NPI: 1164356960
Provider Name (Legal Business Name): CAROLYN ROSE HEISE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/09/2026
Last Update Date: 06/09/2026
Certification Date: 06/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2499 HIGHWAY 7
EXCELSIOR MN
55331-9701
US

IV. Provider business mailing address

2708 DAKOTA AVE S
ST LOUIS PARK MN
55416-1831
US

V. Phone/Fax

Practice location:
  • Phone: 952-252-1070
  • Fax:
Mailing address:
  • Phone: 612-388-2175
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number113718
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: