Basic Information
| Provider Information | |||||||||
| NPI: | 1881988863 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HIETALA | ||||||||
| FirstName: | DOREEN | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | PHARMD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1650 COCHRANE CIR | ||||||||
| Address2: | |||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809134613 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195260827 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1856 IRWIN DR | ||||||||
| Address2: | |||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809134176 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195267266 | ||||||||
| FaxNumber: | 7195267673 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/07/2011 | ||||||||
| LastUpdateDate: | 04/25/2016 | ||||||||
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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 | 1835P0018X | 3260 | WY | Y | Pharmacy Service Providers | Pharmacist | Pharmacist Clinician (PhC)/ Clinical Pharmacy Specialist | 183500000X | 3260 | WY | N | Pharmacy Service Providers | Pharmacist |
No ID Information.