Provider Demographics
NPI:1093758229
Name:HEIDEL, JEANNA C (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:JEANNA
Middle Name:C
Last Name:HEIDEL
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:RR 3 BOX 163
Mailing Address - Street 2:
Mailing Address - City:RUSK
Mailing Address - State:TX
Mailing Address - Zip Code:75785-9527
Mailing Address - Country:US
Mailing Address - Phone:903-683-2045
Mailing Address - Fax:
Practice Address - Street 1:1601 N DICKINSON
Practice Address - Street 2:PHARMACY
Practice Address - City:RUSK
Practice Address - State:TX
Practice Address - Zip Code:75785
Practice Address - Country:US
Practice Address - Phone:903-683-7174
Practice Address - Fax:903-683-7996
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX30088183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX30066OtherSTATE PHARMACIST LISCENSE