Provider Demographics
NPI:1548350986
Name:HETLAND, GEORGIA A (RPH)
Entity type:Individual
Prefix:MRS
First Name:GEORGIA
Middle Name:A
Last Name:HETLAND
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 1:312 6TH AVE NW
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:SD
Mailing Address - Zip Code:57201-2346
Mailing Address - Country:US
Mailing Address - Phone:605-882-2842
Mailing Address - Fax:
Practice Address - Street 1:122 E KEMP
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:SD
Practice Address - Zip Code:57201-3640
Practice Address - Country:US
Practice Address - Phone:605-882-4809
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDR4350183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist