Provider Demographics
NPI:1619016797
Name:HEIDERSCHEIDT, JENNIFER M (RPH)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:M
Last Name:HEIDERSCHEIDT
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:M
Other - Last Name:DREXLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RPH
Mailing Address - Street 1:HC 70 BOX 23
Mailing Address - Street 2:
Mailing Address - City:TONALEA
Mailing Address - State:AZ
Mailing Address - Zip Code:86044-9610
Mailing Address - Country:US
Mailing Address - Phone:605-310-3997
Mailing Address - Fax:
Practice Address - Street 1:HWY 98 AND NAVAJO ROUTE 16
Practice Address - Street 2:
Practice Address - City:TONALEA
Practice Address - State:AZ
Practice Address - Zip Code:86044
Practice Address - Country:US
Practice Address - Phone:928-672-3034
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-06
Last Update Date:2020-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD4526183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist