Provider Demographics
NPI:1689924748
Name:HENEN, HEIDI W
Entity Type:Individual
Prefix:
First Name:HEIDI
Middle Name:W
Last Name:HENEN
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 1:1975 BLOOMING HILLS DR UNIT 201
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86301-6527
Mailing Address - Country:US
Mailing Address - Phone:928-445-0607
Mailing Address - Fax:
Practice Address - Street 1:3100 N GLASSFORD HILL RD
Practice Address - Street 2:
Practice Address - City:PRESCOTT VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:86314-2285
Practice Address - Country:US
Practice Address - Phone:928-445-0607
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-17
Last Update Date:2012-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZS018852183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist