Provider Demographics
NPI:1013991561
Name:DIEZ, HEIDI LYNN (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:HEIDI
Middle Name:LYNN
Last Name:DIEZ
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 1:5629 VERSAILLES AVE
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48103-9084
Mailing Address - Country:US
Mailing Address - Phone:734-929-4156
Mailing Address - Fax:
Practice Address - Street 1:400 S MAPLE RD
Practice Address - Street 2:KROGER PHARMACY ATTN: HEIDI DIEZ
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48103-3835
Practice Address - Country:US
Practice Address - Phone:734-213-5343
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-29
Last Update Date:2007-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH00057161183500000X
MI5302033123183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist