Provider Demographics
NPI:1598106551
Name:HERITAGE PHARMACY & SURGICAL SUPPLIES,CORP
Entity Type:Organization
Organization Name:HERITAGE PHARMACY & SURGICAL SUPPLIES,CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/PHARMACIST
Authorized Official - Prefix:MR
Authorized Official - First Name:BENJAMIN
Authorized Official - Middle Name:C
Authorized Official - Last Name:ONWUDIWE
Authorized Official - Suffix:
Authorized Official - Credentials:BSC,MSC
Authorized Official - Phone:201-952-3764
Mailing Address - Street 1:2258 ADAM CLAYTON POWELL JR BLVD
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10027-7808
Mailing Address - Country:US
Mailing Address - Phone:212-694-8050
Mailing Address - Fax:
Practice Address - Street 1:2258 ADAM CLAYTON POWELL JR BLVD
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10027-7808
Practice Address - Country:US
Practice Address - Phone:212-694-8050
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-07
Last Update Date:2014-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY032074333600000X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
7057390001Medicare NSC