Provider Demographics
NPI:1467564476
Name:HERITAGE PHARMACY INC
Entity Type:Organization
Organization Name:HERITAGE PHARMACY INC
Other - Org Name:HERITAGE HEALTHCARE SERVICES INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SHELLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:HUNTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:740-653-0942
Mailing Address - Street 1:3675 DOLSON CT
Mailing Address - Street 2:
Mailing Address - City:CARROLL
Mailing Address - State:OH
Mailing Address - Zip Code:43112-9721
Mailing Address - Country:US
Mailing Address - Phone:740-653-0942
Mailing Address - Fax:740-653-7372
Practice Address - Street 1:3675 DOLSON CT
Practice Address - Street 2:
Practice Address - City:CARROLL
Practice Address - State:OH
Practice Address - Zip Code:43112-9721
Practice Address - Country:US
Practice Address - Phone:740-653-0942
Practice Address - Fax:740-653-7372
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X, 3336C0004X, 3336I0012X
OH0210904503336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336I0012XSuppliersPharmacyInstitutional Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH3143717Medicaid
2076340OtherPK
OH3143717Medicaid