=====================================================
General NPI Number Information
=====================================================
NPI Number | 1982228003
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MICHAEL PAUL HEIDT PHARMD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/04/2020
-----------------------------------------------------
Last Update Date | 06/04/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 119 E GRAND RIVER AVE
-----------------------------------------------------
City | FOWLERVILLE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48836-5109
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 517-223-9832
-----------------------------------------------------
Fax | 517-223-7267
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2129 RABBIT TRAK
-----------------------------------------------------
City | PINCKNEY
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48169-9508
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 734-347-2528
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 5302026400
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------