Provider Demographics
NPI:1619194453
Name:HERITAGE PARK PHARMACY, LLC
Entity Type:Organization
Organization Name:HERITAGE PARK PHARMACY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHERYL
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:DESJARDINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-737-6697
Mailing Address - Street 1:6908 E RENO AVE STE 101
Mailing Address - Street 2:
Mailing Address - City:MIDWEST CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73110-2120
Mailing Address - Country:US
Mailing Address - Phone:405-737-6697
Mailing Address - Fax:405-737-6698
Practice Address - Street 1:6908 E RENO AVE STE 101
Practice Address - Street 2:
Practice Address - City:MIDWEST CITY
Practice Address - State:OK
Practice Address - Zip Code:73110-2120
Practice Address - Country:US
Practice Address - Phone:405-737-6697
Practice Address - Fax:405-737-6698
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-20
Last Update Date:2014-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKT-6052183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183700000XPharmacy Service ProvidersPharmacy TechnicianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100237240AMedicaid
OK3713218OtherNCPDP