Provider Demographics
NPI:1679063523
Name:HERITAGE PHARMACY LLC
Entity Type:Organization
Organization Name:HERITAGE PHARMACY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:
Authorized Official - Last Name:NELSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:757-243-2764
Mailing Address - Street 1:5922B GEORGE WASHINGTON MEM HWY
Mailing Address - Street 2:
Mailing Address - City:YORKTOWN
Mailing Address - State:VA
Mailing Address - Zip Code:23692-2110
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5922B GEORGE WASHINGTON MEM HWY
Practice Address - Street 2:
Practice Address - City:YORKTOWN
Practice Address - State:VA
Practice Address - Zip Code:23692
Practice Address - Country:US
Practice Address - Phone:757-243-2764
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-16
Last Update Date:2018-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2010048433336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy