Provider Demographics
NPI:1932653672
Name:TIEBEN, HEATH (PHARM D)
Entity Type:Individual
Prefix:
First Name:HEATH
Middle Name:
Last Name:TIEBEN
Suffix:
Gender:M
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1905 N 14TH AVE
Mailing Address - Street 2:
Mailing Address - City:DODGE CITY
Mailing Address - State:KS
Mailing Address - Zip Code:67801-2304
Mailing Address - Country:US
Mailing Address - Phone:620-225-0872
Mailing Address - Fax:620-225-0717
Practice Address - Street 1:1905 N 14TH AVE
Practice Address - Street 2:
Practice Address - City:DODGE CITY
Practice Address - State:KS
Practice Address - Zip Code:67801-2304
Practice Address - Country:US
Practice Address - Phone:620-225-0872
Practice Address - Fax:620-225-0717
Is Sole Proprietor?:No
Enumeration Date:2016-08-11
Last Update Date:2016-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1-17032183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist