Provider Demographics
NPI:1346620887
Name:HEALY, ERIC JON
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:JON
Last Name:HEALY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2360 TORI WAY
Mailing Address - Street 2:
Mailing Address - City:OAKDALE
Mailing Address - State:CA
Mailing Address - Zip Code:95361-8925
Mailing Address - Country:US
Mailing Address - Phone:801-712-4255
Mailing Address - Fax:
Practice Address - Street 1:350 S OAK AVE
Practice Address - Street 2:
Practice Address - City:OAKDALE
Practice Address - State:CA
Practice Address - Zip Code:95361-3519
Practice Address - Country:US
Practice Address - Phone:209-848-4165
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-05-30
Last Update Date:2021-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5250158-1701183500000X
CA60291183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist