Provider Demographics
NPI:1306283965
Name:HEVERLY, ROBERT W (RPH)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:W
Last Name:HEVERLY
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 1:760 BROAD ST
Mailing Address - Street 2:
Mailing Address - City:MONTOURSVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:17754-2419
Mailing Address - Country:US
Mailing Address - Phone:570-368-2629
Mailing Address - Fax:570-368-7435
Practice Address - Street 1:760 BROAD ST
Practice Address - Street 2:
Practice Address - City:MONTOURSVILLE
Practice Address - State:PA
Practice Address - Zip Code:17754-2419
Practice Address - Country:US
Practice Address - Phone:570-368-2629
Practice Address - Fax:570-368-7435
Is Sole Proprietor?:No
Enumeration Date:2013-05-22
Last Update Date:2013-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARP039014L183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PARP039014LOtherPA PHARMACY LICENSE
PARPI005219OtherPA IMMUNIZATION LICENSE