Provider Demographics
NPI:1013283274
Name:ELIASON, HEIDI DOREEN (RPH)
Entity Type:Individual
Prefix:
First Name:HEIDI
Middle Name:DOREEN
Last Name:ELIASON
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2700
Mailing Address - Street 2:
Mailing Address - City:HAILEY
Mailing Address - State:ID
Mailing Address - Zip Code:83333-2700
Mailing Address - Country:US
Mailing Address - Phone:208-788-9714
Mailing Address - Fax:208-788-2966
Practice Address - Street 1:91 E CROY ST
Practice Address - Street 2:
Practice Address - City:HAILEY
Practice Address - State:ID
Practice Address - Zip Code:83333-8407
Practice Address - Country:US
Practice Address - Phone:208-788-9714
Practice Address - Fax:208-799-2966
Is Sole Proprietor?:No
Enumeration Date:2012-03-31
Last Update Date:2012-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP4623183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist