Healthcare Provider Details

I. General information

NPI: 1720538507
Provider Name (Legal Business Name): VIVIENE HEITLAGE PHARM.D
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/05/2016
Last Update Date: 10/05/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

701 PARK AVE
MINNEAPOLIS MN
55415-1623
US

IV. Provider business mailing address

580 COUNTY ROAD B2 E
LITTLE CANADA MN
55117-1611
US

V. Phone/Fax

Practice location:
  • Phone: 612-873-2908
  • Fax:
Mailing address:
  • Phone: 321-662-1783
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P1200X
TaxonomyPharmacotherapy Pharmacist
License Number121008
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: