Provider Demographics
NPI:1881866903
Name:DELFORGE, HEATHER A (PHARMD)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:A
Last Name:DELFORGE
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 1:712 MIDWAY RD
Mailing Address - Street 2:
Mailing Address - City:MENASHA
Mailing Address - State:WI
Mailing Address - Zip Code:54952-1014
Mailing Address - Country:US
Mailing Address - Phone:920-722-1378
Mailing Address - Fax:
Practice Address - Street 1:712 MIDWAY RD
Practice Address - Street 2:
Practice Address - City:MENASHA
Practice Address - State:WI
Practice Address - Zip Code:54952-1014
Practice Address - Country:US
Practice Address - Phone:920-722-1378
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-03-28
Last Update Date:2008-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI14114-40183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist