Provider Demographics
NPI:1124301486
Name:HEBACKER, CORNELIA W (PHARMD)
Entity type:Individual
Prefix:
First Name:CORNELIA
Middle Name:W
Last Name:HEBACKER
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 W HARDING WAY
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95204-5716
Mailing Address - Country:US
Mailing Address - Phone:209-941-9632
Mailing Address - Fax:209-941-2068
Practice Address - Street 1:15 W HARDING WAY
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95204-5716
Practice Address - Country:US
Practice Address - Phone:209-941-9632
Practice Address - Fax:209-941-2068
Is Sole Proprietor?:No
Enumeration Date:2011-09-23
Last Update Date:2011-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA042303183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist