Healthcare Provider Details

I. General information

NPI: 1841776978
Provider Name (Legal Business Name): HEATHER COLLINS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/11/2018
Last Update Date: 07/11/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10070 GRAVOIS RD
AFFTON MO
63123-4024
US

IV. Provider business mailing address

10070 GRAVOIS RD
AFFTON MO
63123-4024
US

V. Phone/Fax

Practice location:
  • Phone: 314-631-6781
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number2012026229
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: