Provider Demographics
NPI:1720683006
Name:SMITH, HEATHER MICHELE (PHD)
Entity Type:Individual
Prefix:DR
First Name:HEATHER
Middle Name:MICHELE
Last Name:SMITH
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11545 OLD HIGHWAY 49
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39503-2874
Mailing Address - Country:US
Mailing Address - Phone:228-284-3689
Mailing Address - Fax:228-284-3690
Practice Address - Street 1:11545 OLD HIGHWAY 49
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39503-2874
Practice Address - Country:US
Practice Address - Phone:228-284-3689
Practice Address - Fax:228-284-3690
Is Sole Proprietor?:No
Enumeration Date:2020-12-03
Last Update Date:2022-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSE-15653183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist