Basic Information
| Provider Information | |||||||||
| NPI: | 1326277872 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FAHEY | ||||||||
| FirstName: | HEATHER | ||||||||
| MiddleName: | MARACLE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PHARM.D | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MARACLE | ||||||||
| OtherFirstName: | HEATHER | ||||||||
| OtherMiddleName: | |||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 711 KASOTA AVE SE | ||||||||
| Address2: | MTM PHARMACY | ||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554142842 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6126727955 | ||||||||
| FaxNumber: | 6126727320 | ||||||||
| Practice Location | |||||||||
| Address1: | 1151 SILVER LAKE RD NW | ||||||||
| Address2: | |||||||||
| City: | NEW BRIGHTON | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551126324 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6517462575 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/06/2009 | ||||||||
| LastUpdateDate: | 03/07/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183500000X | 119729 | MN | Y | Pharmacy Service Providers | Pharmacist |
No ID Information.