Provider Demographics
NPI:1376845362
Name:PEACOCK, HEATHER (PHARMD)
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:
Last Name:PEACOCK
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 1:1235 CLAYTON LN
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA FALLS
Mailing Address - State:MT
Mailing Address - Zip Code:59912-4495
Mailing Address - Country:US
Mailing Address - Phone:406-892-0299
Mailing Address - Fax:
Practice Address - Street 1:20 FOUR MILE DR
Practice Address - Street 2:SUITE 3
Practice Address - City:KALISPELL
Practice Address - State:MT
Practice Address - Zip Code:59901-2632
Practice Address - Country:US
Practice Address - Phone:406-752-0440
Practice Address - Fax:406-752-0443
Is Sole Proprietor?:No
Enumeration Date:2010-11-23
Last Update Date:2012-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT6324183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist