Provider Demographics
NPI:1093183303
Name:HERITAGE COMPOUNDING PHARMACY
Entity Type:Organization
Organization Name:HERITAGE COMPOUNDING PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST IN CHARGE
Authorized Official - Prefix:DR
Authorized Official - First Name:SYLVIA
Authorized Official - Middle Name:A
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:714-579-1636
Mailing Address - Street 1:30802 COAST HWY
Mailing Address - Street 2:SPC. D8
Mailing Address - City:LAGUNA BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92651-4207
Mailing Address - Country:US
Mailing Address - Phone:949-235-0343
Mailing Address - Fax:714-579-1682
Practice Address - Street 1:2903 SATURN ST STE A
Practice Address - Street 2:
Practice Address - City:BREA
Practice Address - State:CA
Practice Address - Zip Code:92821-6259
Practice Address - Country:US
Practice Address - Phone:714-579-1636
Practice Address - Fax:714-579-1682
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-03
Last Update Date:2015-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA22225183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty