Provider Demographics
NPI:1326628256
Name:IMMLER, HAIVAN (PHARMD)
Entity Type:Individual
Prefix:
First Name:HAIVAN
Middle Name:
Last Name:IMMLER
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 1:700 ESSEX CT
Mailing Address - Street 2:
Mailing Address - City:SOUTHLAKE
Mailing Address - State:TX
Mailing Address - Zip Code:76092-7119
Mailing Address - Country:US
Mailing Address - Phone:682-365-3836
Mailing Address - Fax:
Practice Address - Street 1:6601 HARRIS PKWY
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76132-6108
Practice Address - Country:US
Practice Address - Phone:817-433-9600
Practice Address - Fax:888-593-8498
Is Sole Proprietor?:No
Enumeration Date:2021-04-13
Last Update Date:2021-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX682701835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist