Provider Demographics
NPI:1124312319
Name:HEITZ, THERESA M (PHARM D)
Entity type:Individual
Prefix:DR
First Name:THERESA
Middle Name:M
Last Name:HEITZ
Suffix:
Gender:F
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 1:2555 SYCAMORE RD
Mailing Address - Street 2:
Mailing Address - City:DEKALB
Mailing Address - State:IL
Mailing Address - Zip Code:60115-2051
Mailing Address - Country:US
Mailing Address - Phone:815-787-6971
Mailing Address - Fax:815-787-6971
Practice Address - Street 1:2555 SYCAMORE RD
Practice Address - Street 2:
Practice Address - City:DEKALB
Practice Address - State:IL
Practice Address - Zip Code:60115-2051
Practice Address - Country:US
Practice Address - Phone:815-787-6971
Practice Address - Fax:815-787-6971
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-05
Last Update Date:2011-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051291042183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist