Provider Demographics
NPI:1780284901
Name:HEINTZ, KIMBERLY KAY
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:KAY
Last Name:HEINTZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3718 HARBOR LN
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:IL
Mailing Address - Zip Code:62305-8395
Mailing Address - Country:US
Mailing Address - Phone:217-430-0272
Mailing Address - Fax:
Practice Address - Street 1:5211 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:QUINCY
Practice Address - State:IL
Practice Address - Zip Code:62305-9122
Practice Address - Country:US
Practice Address - Phone:217-228-2331
Practice Address - Fax:217-228-2339
Is Sole Proprietor?:No
Enumeration Date:2020-10-27
Last Update Date:2020-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051037699183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist