Provider Demographics
NPI:1871194225
Name:FOUNTAIN, HEATHER ASHLEE (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:HEATHER
Middle Name:ASHLEE
Last Name:FOUNTAIN
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1123 ALDERLY LN
Mailing Address - Street 2:
Mailing Address - City:WARNER ROBINS
Mailing Address - State:GA
Mailing Address - Zip Code:31088-2221
Mailing Address - Country:US
Mailing Address - Phone:573-586-6964
Mailing Address - Fax:
Practice Address - Street 1:502 BOOTH RD
Practice Address - Street 2:
Practice Address - City:WARNER ROBINS
Practice Address - State:GA
Practice Address - Zip Code:31088-3422
Practice Address - Country:US
Practice Address - Phone:478-918-0678
Practice Address - Fax:478-918-0675
Is Sole Proprietor?:No
Enumeration Date:2020-11-03
Last Update Date:2020-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2007025733183500000X
GA031295183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist