Provider Demographics
NPI:1609959766
Name:HEART PHARMACY, INC
Entity Type:Organization
Organization Name:HEART PHARMACY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO / CHIEF PHARMACIST
Authorized Official - Prefix:MR
Authorized Official - First Name:MARVIN
Authorized Official - Middle Name:WEYMAN
Authorized Official - Last Name:GRIFFIN
Authorized Official - Suffix:SR
Authorized Official - Credentials:RPH
Authorized Official - Phone:770-997-6500
Mailing Address - Street 1:706 SPRINGDALE DR
Mailing Address - Street 2:
Mailing Address - City:RIVERDALE
Mailing Address - State:GA
Mailing Address - Zip Code:30274-2327
Mailing Address - Country:US
Mailing Address - Phone:770-997-6500
Mailing Address - Fax:770-909-0737
Practice Address - Street 1:706 SPRINGDALE DR
Practice Address - Street 2:
Practice Address - City:RIVERDALE
Practice Address - State:GA
Practice Address - Zip Code:30274-2327
Practice Address - Country:US
Practice Address - Phone:770-997-6500
Practice Address - Fax:770-909-0737
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-23
Last Update Date:2014-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA9038333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1113238OtherNABP
GA000054711AMedicaid
GA6708060001Medicare NSC