Provider Demographics
NPI:1326291238
Name:HERITAGE PHARMACY GATEWAY MALL INC
Entity Type:Organization
Organization Name:HERITAGE PHARMACY GATEWAY MALL INC
Other - Org Name:HERITAGE PHARMACY GATEWAY MALL INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LUCAS
Authorized Official - Middle Name:
Authorized Official - Last Name:HOECHST
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:701-530-5800
Mailing Address - Street 1:2700 STATE ST
Mailing Address - Street 2:STE F13
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58503-0669
Mailing Address - Country:US
Mailing Address - Phone:701-530-5800
Mailing Address - Fax:701-530-5805
Practice Address - Street 1:2700 STATE ST
Practice Address - Street 2:STE F13
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58503-0669
Practice Address - Country:US
Practice Address - Phone:701-530-5800
Practice Address - Fax:701-530-5805
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-23
Last Update Date:2017-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
NDPHAR7793336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND1455717Medicaid
2118069OtherPK
ND1455717Medicaid