Healthcare Provider Details

I. General information

NPI: 1619630092
Provider Name (Legal Business Name): CHARLES JOHN HEPPNER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/21/2021
Last Update Date: 10/29/2021
Certification Date: 10/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6259 MAYFIELD RD
MAYFIELD HTS OH
44124-3217
US

IV. Provider business mailing address

6259 MAYFIELD RD
MAYFIELD HTS OH
44124-3217
US

V. Phone/Fax

Practice location:
  • Phone: 440-449-3940
  • Fax:
Mailing address:
  • Phone: 440-449-3940
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number03112354
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: