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General NPI Number Information
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NPI Number | 1538446562
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Entity Type | Individual
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Provider Name | EDWARD B HEIMSTREET RPH
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Gender | Male
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Dates
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Enumeration Date | 11/04/2011
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Last Update Date | 11/04/2011
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Provider Practice Location Address
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Address Line | 812 N MAIN ST
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City | LAKE MILLS
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State | WI
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Zip | 53551-1117
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Country | US
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Telephone | 920-648-5187
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Fax | 920-648-5976
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Provider Business Mailing Address
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Address Line | 812 N MAIN ST
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City | LAKE MILLS
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State | WI
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Zip | 53551-1117
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Country | US
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Telephone | 920-648-5187
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Fax | 920-648-5976
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 183500000X
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Taxonomy Name | Pharmacist
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License Number | 10454-040
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License Number State | WI
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