Healthcare Provider Details

I. General information

NPI: 1427455468
Provider Name (Legal Business Name): THEODORE HEUN PHARMACIST
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/19/2014
Last Update Date: 11/19/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1735 W SILVER SPRING DR
GLENDALE WI
53209-4400
US

IV. Provider business mailing address

6060 N IRONWOOD LN
GLENDALE WI
53217-4423
US

V. Phone/Fax

Practice location:
  • Phone: 414-247-8591
  • Fax: 414-247-8603
Mailing address:
  • Phone: 414-961-8899
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number9457-40
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: