Provider Demographics
NPI:1548423338
Name:HEARTLAND PHARMACY - IDAHO FALLS
Entity Type:Organization
Organization Name:HEARTLAND PHARMACY - IDAHO FALLS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:REECE
Authorized Official - Middle Name:
Authorized Official - Last Name:CHRISTENSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-497-3575
Mailing Address - Street 1:1790 SABIN DR
Mailing Address - Street 2:
Mailing Address - City:AMMON
Mailing Address - State:ID
Mailing Address - Zip Code:83406-6747
Mailing Address - Country:US
Mailing Address - Phone:208-497-3575
Mailing Address - Fax:208-552-2103
Practice Address - Street 1:3250 E 17TH ST
Practice Address - Street 2:
Practice Address - City:AMMON
Practice Address - State:ID
Practice Address - Zip Code:83406-6758
Practice Address - Country:US
Practice Address - Phone:208-552-7677
Practice Address - Fax:208-552-2103
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-02
Last Update Date:2020-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID1624LS332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID806141400Medicaid
WA2038144Medicaid
UT1548423338Medicaid
MT0562258Medicaid
UT1548423338Medicaid