Provider Demographics
NPI:1366980484
Name:THEBODO, HEATHER H (RPH)
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:H
Last Name:THEBODO
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 1:47-49 LAKE AVENUE EXTENTION
Mailing Address - Street 2:
Mailing Address - City:DANBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06811
Mailing Address - Country:US
Mailing Address - Phone:203-778-7471
Mailing Address - Fax:203-778-7477
Practice Address - Street 1:47-49 LAKE AVENUE EXTENTION
Practice Address - Street 2:
Practice Address - City:DANBURY
Practice Address - State:CT
Practice Address - Zip Code:06811
Practice Address - Country:US
Practice Address - Phone:203-778-7471
Practice Address - Fax:203-778-7477
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-09
Last Update Date:2017-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT7803183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist