Provider Demographics
NPI:1992305130
Name:EADES, HEATHER DAWN BOSWELL
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:DAWN BOSWELL
Last Name:EADES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:724 BROAD STREET RD
Mailing Address - Street 2:
Mailing Address - City:MANAKIN SABOT
Mailing Address - State:VA
Mailing Address - Zip Code:23103-2406
Mailing Address - Country:US
Mailing Address - Phone:804-937-8946
Mailing Address - Fax:
Practice Address - Street 1:9440 W BROAD ST
Practice Address - Street 2:
Practice Address - City:HENRICO
Practice Address - State:VA
Practice Address - Zip Code:23294-5330
Practice Address - Country:US
Practice Address - Phone:804-747-9160
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-27
Last Update Date:2020-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA02022062201835G0303X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835G0303XPharmacy Service ProvidersPharmacistGeriatric