Provider Demographics
NPI:1073139820
Name:HEISNER, ROBERT ERHARDT II (DOCTOR OF PHARMACY)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:ERHARDT
Last Name:HEISNER
Suffix:II
Gender:M
Credentials:DOCTOR OF PHARMACY
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:204 S WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:DU QUOIN
Mailing Address - State:IL
Mailing Address - Zip Code:62832-1805
Mailing Address - Country:US
Mailing Address - Phone:618-542-2575
Mailing Address - Fax:618-542-3688
Practice Address - Street 1:204 S WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:DU QUOIN
Practice Address - State:IL
Practice Address - Zip Code:62832-1805
Practice Address - Country:US
Practice Address - Phone:618-542-2575
Practice Address - Fax:618-542-3688
Is Sole Proprietor?:No
Enumeration Date:2020-06-17
Last Update Date:2020-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051.297016183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL043733824002Medicaid