Provider Demographics
NPI:1962739573
Name:HEERSINK, STACI LEANNE (RPH)
Entity type:Individual
Prefix:
First Name:STACI
Middle Name:LEANNE
Last Name:HEERSINK
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1505 OLD FARM RD
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75703-0338
Mailing Address - Country:US
Mailing Address - Phone:214-415-0234
Mailing Address - Fax:
Practice Address - Street 1:2120 ESE LOOP323
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-8318
Practice Address - Country:US
Practice Address - Phone:903-593-1507
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-03
Last Update Date:2020-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX37851183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist