Healthcare Provider Details

I. General information

NPI: 1497390371
Provider Name (Legal Business Name): DAVID HEFFERNAN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/14/2019
Last Update Date: 11/14/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

69 FARNWOOD RD
MOUNT LAUREL NJ
08054-2913
US

IV. Provider business mailing address

69 FARNWOOD RD
MOUNT LAUREL NJ
08054-2913
US

V. Phone/Fax

Practice location:
  • Phone: 609-841-6918
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number28RI01967400
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: