Provider Demographics
NPI:1154811347
Name:HEINEMAN, CARL MICHAEL (RPH)
Entity type:Individual
Prefix:MR
First Name:CARL
Middle Name:MICHAEL
Last Name:HEINEMAN
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 1:256 BUNKER HILL AVE
Mailing Address - Street 2:
Mailing Address - City:WATERBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06708-2253
Mailing Address - Country:US
Mailing Address - Phone:203-574-7825
Mailing Address - Fax:
Practice Address - Street 1:556 NORTHFIELD RD
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:CT
Practice Address - Zip Code:06795-1503
Practice Address - Country:US
Practice Address - Phone:860-417-3471
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-14
Last Update Date:2018-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT48663336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004027306Medicaid