Provider Demographics
NPI:1407857683
Name:HELLER, MARK RONALD (RPH, CPH)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:RONALD
Last Name:HELLER
Suffix:
Gender:M
Credentials:RPH, CPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5905 NW 124TH ST
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32653-2639
Mailing Address - Country:US
Mailing Address - Phone:352-332-7283
Mailing Address - Fax:352-332-7283
Practice Address - Street 1:5905 NW 124TH ST
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32653-2639
Practice Address - Country:US
Practice Address - Phone:352-332-7283
Practice Address - Fax:352-332-7283
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-10
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL21692183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist