Provider Demographics
NPI:1477848018
Name:WIKTOR, HEATHER MARIE
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:MARIE
Last Name:WIKTOR
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 NICOLLET MALL # 272
Mailing Address - Street 2:T2769
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55403-2542
Mailing Address - Country:US
Mailing Address - Phone:612-354-5914
Mailing Address - Fax:612-354-5915
Practice Address - Street 1:1000 NICOLLET MALL # 272
Practice Address - Street 2:T2769
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55403-2542
Practice Address - Country:US
Practice Address - Phone:612-354-5914
Practice Address - Fax:612-354-5915
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-11
Last Update Date:2015-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA60228183500000X
MN120732183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist