Provider Demographics
NPI:1538446562
Name:HEIMSTREET, EDWARD B (RPH)
Entity type:Individual
Prefix:
First Name:EDWARD
Middle Name:B
Last Name:HEIMSTREET
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 1:812 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LAKE MILLS
Mailing Address - State:WI
Mailing Address - Zip Code:53551-1117
Mailing Address - Country:US
Mailing Address - Phone:920-648-5187
Mailing Address - Fax:920-648-5976
Practice Address - Street 1:812 N MAIN ST
Practice Address - Street 2:
Practice Address - City:LAKE MILLS
Practice Address - State:WI
Practice Address - Zip Code:53551-1117
Practice Address - Country:US
Practice Address - Phone:920-648-5187
Practice Address - Fax:920-648-5976
Is Sole Proprietor?:No
Enumeration Date:2011-11-04
Last Update Date:2011-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI10454-040183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist