Provider Demographics
NPI:1992097000
Name:HEARNE, KARL W (RPH)
Entity type:Individual
Prefix:MR
First Name:KARL
Middle Name:W
Last Name:HEARNE
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 1:400 S WOODRUFF AVE
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83401-4367
Mailing Address - Country:US
Mailing Address - Phone:208-529-5300
Mailing Address - Fax:208-529-0940
Practice Address - Street 1:400 S WOODRUFF AVE
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83401-4367
Practice Address - Country:US
Practice Address - Phone:208-529-5300
Practice Address - Fax:208-529-0940
Is Sole Proprietor?:No
Enumeration Date:2011-05-07
Last Update Date:2011-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP5712183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist