Healthcare Provider Details

I. General information

NPI: 1730164799
Provider Name (Legal Business Name): MARTIN HEIM III PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 12/13/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

164 CARROLL ST
LEBANON VA
24266-4510
US

IV. Provider business mailing address

111 VALLEY POINTE
RICHLANDS VA
24641-2888
US

V. Phone/Fax

Practice location:
  • Phone: 276-889-3700
  • Fax:
Mailing address:
  • Phone: 706-566-2046
  • Fax: 276-935-4279

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P1200X
TaxonomyPharmacotherapy Pharmacist
License Number0202207232
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code1835P1200X
TaxonomyPharmacotherapy Pharmacist
License NumberRPH022515
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code1835P1200X
TaxonomyPharmacotherapy Pharmacist
License Number16593
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: