Provider Demographics
NPI:1063833879
Name:PETRIE, HEATHER (PHARMD, CPH)
Entity type:Individual
Prefix:DR
First Name:HEATHER
Middle Name:
Last Name:PETRIE
Suffix:
Gender:F
Credentials:PHARMD, CPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4175 S PIPKIN RD
Mailing Address - Street 2:SUITE 208
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33811-1699
Mailing Address - Country:US
Mailing Address - Phone:863-577-1440
Mailing Address - Fax:863-577-1444
Practice Address - Street 1:4175 S PIPKIN RD
Practice Address - Street 2:SUITE 208
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33811-1699
Practice Address - Country:US
Practice Address - Phone:863-577-1440
Practice Address - Fax:863-577-1444
Is Sole Proprietor?:No
Enumeration Date:2013-12-20
Last Update Date:2013-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS48532183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist