Provider Demographics
NPI:1780284794
Name:HEIM, JOHNATHAN GREGORY (PHARMD)
Entity type:Individual
Prefix:DR
First Name:JOHNATHAN
Middle Name:GREGORY
Last Name:HEIM
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2001 S 1ST ST
Mailing Address - Street 2:
Mailing Address - City:CHICKASHA
Mailing Address - State:OK
Mailing Address - Zip Code:73018-6007
Mailing Address - Country:US
Mailing Address - Phone:405-224-0292
Mailing Address - Fax:405-224-0296
Practice Address - Street 1:2001 S 1ST ST
Practice Address - Street 2:
Practice Address - City:CHICKASHA
Practice Address - State:OK
Practice Address - Zip Code:73018-6007
Practice Address - Country:US
Practice Address - Phone:405-224-0292
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-28
Last Update Date:2020-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK18866183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK18866OtherSTATE LICENSE