Provider Demographics
NPI:1033133947
Name:HEIDBREDER, DOUGLAS ERIC (RPH)
Entity Type:Individual
Prefix:MR
First Name:DOUGLAS
Middle Name:ERIC
Last Name:HEIDBREDER
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 349
Mailing Address - Street 2:100 W. MAIN STREET
Mailing Address - City:ADDISON
Mailing Address - State:MI
Mailing Address - Zip Code:49220
Mailing Address - Country:US
Mailing Address - Phone:517-547-6686
Mailing Address - Fax:517-547-3401
Practice Address - Street 1:100 W. MAIN STREET
Practice Address - Street 2:
Practice Address - City:ADDISON
Practice Address - State:MI
Practice Address - Zip Code:49220
Practice Address - Country:US
Practice Address - Phone:517-547-6686
Practice Address - Fax:517-547-3401
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2012-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302026194183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist