Provider Demographics
NPI:1710954631
Name:HERITAGE PHARMACY INC
Entity Type:Organization
Organization Name:HERITAGE PHARMACY INC
Other - Org Name:HERITAGE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:HUNTER
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:740-653-0942
Mailing Address - Street 1:3675 DOLSON CT
Mailing Address - Street 2:
Mailing Address - City:CARROLL
Mailing Address - State:OH
Mailing Address - Zip Code:43112-9721
Mailing Address - Country:US
Mailing Address - Phone:740-653-0942
Mailing Address - Fax:740-654-5041
Practice Address - Street 1:3675 DOLSON CT
Practice Address - Street 2:
Practice Address - City:CARROLL
Practice Address - State:OH
Practice Address - Zip Code:43112-9721
Practice Address - Country:US
Practice Address - Phone:740-653-0942
Practice Address - Fax:740-654-5041
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-01
Last Update Date:2016-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X
OH0201501503336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0510361497Medicaid
3633460OtherNCPDP PROVIDER IDENTIFICATION NUMBER