Provider Demographics
NPI:1710056445
Name:HEARTLAND PHARMACY - BOISE
Entity Type:Organization
Organization Name:HEARTLAND PHARMACY - BOISE
Other - Org Name:HEARTLAND LTC PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE ASSISTANT
Authorized Official - Prefix:
Authorized Official - First Name:ANDREA
Authorized Official - Middle Name:
Authorized Official - Last Name:FERGUSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-497-3575
Mailing Address - Street 1:1790 SABIN DR
Mailing Address - Street 2:
Mailing Address - City:AMMON
Mailing Address - State:ID
Mailing Address - Zip Code:83406-6747
Mailing Address - Country:US
Mailing Address - Phone:208-497-3575
Mailing Address - Fax:208-552-2103
Practice Address - Street 1:8455 W EMERALD ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-8306
Practice Address - Country:US
Practice Address - Phone:208-323-0067
Practice Address - Fax:208-323-5954
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-07
Last Update Date:2020-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
ID1679LS3336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID805127900Medicaid
2021934OtherPK
ID805127900Medicaid