Provider Demographics
NPI:1083964787
Name:HEARTLAND PHARMACY 2 LLC
Entity Type:Organization
Organization Name:HEARTLAND PHARMACY 2 LLC
Other - Org Name:HEARTLAND PHARMACY 2 LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KINDY
Authorized Official - Middle Name:
Authorized Official - Last Name:GHUSSIN
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:937-829-1012
Mailing Address - Street 1:2749 W ALEX BELL RD
Mailing Address - Street 2:
Mailing Address - City:MORAINE
Mailing Address - State:OH
Mailing Address - Zip Code:45459-1123
Mailing Address - Country:US
Mailing Address - Phone:937-395-3690
Mailing Address - Fax:937-395-3694
Practice Address - Street 1:2749 W ALEX BELL RD
Practice Address - Street 2:
Practice Address - City:MORAINE
Practice Address - State:OH
Practice Address - Zip Code:45459-1123
Practice Address - Country:US
Practice Address - Phone:937-395-3690
Practice Address - Fax:937-395-3694
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-11
Last Update Date:2015-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X, 3336C0004X
OH0222435503336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2137123OtherPK
OH0073255Medicaid