Provider Demographics
NPI:1891253043
Name:HEIRD, TIM (DPH)
Entity Type:Individual
Prefix:
First Name:TIM
Middle Name:
Last Name:HEIRD
Suffix:
Gender:M
Credentials:DPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1910 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:OK
Mailing Address - Zip Code:74354-2132
Mailing Address - Country:US
Mailing Address - Phone:918-542-4795
Mailing Address - Fax:918-542-6019
Practice Address - Street 1:1910 N MAIN ST
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:OK
Practice Address - Zip Code:74354-2132
Practice Address - Country:US
Practice Address - Phone:918-542-4795
Practice Address - Fax:918-542-6019
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-06
Last Update Date:2019-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK13174183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty