Provider Demographics
NPI:1487115184
Name:HEINEMAN, DAVID JACKSON (PHARMD)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:JACKSON
Last Name:HEINEMAN
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11818 97TH LN NE APT C430
Mailing Address - Street 2:
Mailing Address - City:KIRKLAND
Mailing Address - State:WA
Mailing Address - Zip Code:98034-8975
Mailing Address - Country:US
Mailing Address - Phone:630-204-2093
Mailing Address - Fax:
Practice Address - Street 1:2921 NACHES AVE SW
Practice Address - Street 2:
Practice Address - City:RENTON
Practice Address - State:WA
Practice Address - Zip Code:98057-2617
Practice Address - Country:US
Practice Address - Phone:800-245-7979
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-26
Last Update Date:2019-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH60684606183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist