Provider Demographics
NPI:1467738849
Name:HEFFERNAN, COREY ROBERT (PHARM D)
Entity Type:Individual
Prefix:
First Name:COREY
Middle Name:ROBERT
Last Name:HEFFERNAN
Suffix:
Gender:M
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:103 GLACIER DR
Mailing Address - Street 2:
Mailing Address - City:LOLO
Mailing Address - State:MT
Mailing Address - Zip Code:59847-8700
Mailing Address - Country:US
Mailing Address - Phone:406-273-2322
Mailing Address - Fax:406-273-4208
Practice Address - Street 1:103 GLACIER DR
Practice Address - Street 2:
Practice Address - City:LOLO
Practice Address - State:MT
Practice Address - Zip Code:59847-8700
Practice Address - Country:US
Practice Address - Phone:406-273-2322
Practice Address - Fax:406-273-4208
Is Sole Proprietor?:No
Enumeration Date:2011-10-28
Last Update Date:2020-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT5859183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist