Provider Demographics
NPI:1629568795
Name:HERRON PHARMACY LLC
Entity Type:Organization
Organization Name:HERRON PHARMACY LLC
Other - Org Name:SUMPTER PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LESLIE
Authorized Official - Middle Name:
Authorized Official - Last Name:HERRON
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:360-420-6401
Mailing Address - Street 1:628 NILE KINNICK DR S STE 1
Mailing Address - Street 2:
Mailing Address - City:ADEL
Mailing Address - State:IA
Mailing Address - Zip Code:50003-2071
Mailing Address - Country:US
Mailing Address - Phone:360-420-6401
Mailing Address - Fax:515-993-1116
Practice Address - Street 1:628 NILE KINNICK DR S STE 1
Practice Address - Street 2:
Practice Address - City:ADEL
Practice Address - State:IA
Practice Address - Zip Code:50003-2071
Practice Address - Country:US
Practice Address - Phone:515-993-1119
Practice Address - Fax:866-684-2966
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-15
Last Update Date:2023-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA16453336C0003X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0712155Medicaid