Provider Demographics
NPI:1386892669
Name:HEINTZELMAN, BRIAN JAMES (PHARMD;RPH)
Entity type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:JAMES
Last Name:HEINTZELMAN
Suffix:
Gender:M
Credentials:PHARMD;RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:91 BRENTWOOD CIR
Mailing Address - Street 2:
Mailing Address - City:BLOOMSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17815-7739
Mailing Address - Country:US
Mailing Address - Phone:570-898-0993
Mailing Address - Fax:570-321-2819
Practice Address - Street 1:777 RURAL AVE
Practice Address - Street 2:SL2 EAST
Practice Address - City:WILLIAMSPORT
Practice Address - State:PA
Practice Address - Zip Code:17701-3109
Practice Address - Country:US
Practice Address - Phone:570-321-2818
Practice Address - Fax:570-321-2819
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-29
Last Update Date:2008-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARP441016183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PARPI000520OtherPA AUTHORIZATION TO ADMINISTER INJECTABLES