Provider Demographics
NPI:1508455700
Name:HEATH, MICHAEL DAVID (CPHT)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:DAVID
Last Name:HEATH
Suffix:
Gender:M
Credentials:CPHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:603 LOUIS HENNA BLVD # A
Mailing Address - Street 2:
Mailing Address - City:ROUND ROCK
Mailing Address - State:TX
Mailing Address - Zip Code:78664-7186
Mailing Address - Country:US
Mailing Address - Phone:512-828-0814
Mailing Address - Fax:
Practice Address - Street 1:603 LOUIS HENNA BLVD # A
Practice Address - Street 2:
Practice Address - City:ROUND ROCK
Practice Address - State:TX
Practice Address - Zip Code:78664-7186
Practice Address - Country:US
Practice Address - Phone:512-828-0814
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-12
Last Update Date:2021-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX136134183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician