Provider Demographics
NPI:1982107199
Name:HEACOX, EDWARD (RPH)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:
Last Name:HEACOX
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 HUNTING RDG
Mailing Address - Street 2:
Mailing Address - City:SHARON
Mailing Address - State:CT
Mailing Address - Zip Code:06069-2463
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:99 S CANAAN RD
Practice Address - Street 2:
Practice Address - City:CANAAN
Practice Address - State:CT
Practice Address - Zip Code:06018-2502
Practice Address - Country:US
Practice Address - Phone:860-824-3822
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-14
Last Update Date:2018-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTPCT.0006283183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT022756516OtherDRIVERS LICENSE