Provider Demographics
NPI:1821292699
Name:HEIDEMANN, SARA YOLANDA
Entity Type:Individual
Prefix:MRS
First Name:SARA
Middle Name:YOLANDA
Last Name:HEIDEMANN
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 1:2762 DIAMOND LOOP
Mailing Address - Street 2:C
Mailing Address - City:MILTON
Mailing Address - State:WA
Mailing Address - Zip Code:98354-8304
Mailing Address - Country:US
Mailing Address - Phone:253-927-2910
Mailing Address - Fax:
Practice Address - Street 1:10510 GRAVELLY LAKE DR SW
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:WA
Practice Address - Zip Code:98499-5036
Practice Address - Country:US
Practice Address - Phone:253-589-7190
Practice Address - Fax:253-284-4385
Is Sole Proprietor?:No
Enumeration Date:2007-06-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH00017202183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist