Provider Demographics
NPI:1770029613
Name:HERITAGE PHARMACY EAST INC
Entity Type:Organization
Organization Name:HERITAGE PHARMACY EAST INC
Other - Org Name:HERITAGE PHARMACY MAIN
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:
Authorized Official - Last Name:KRISTENSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:701-530-6050
Mailing Address - Street 1:401 N 9TH ST
Mailing Address - Street 2:
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58501-4530
Mailing Address - Country:US
Mailing Address - Phone:701-530-6050
Mailing Address - Fax:701-530-6417
Practice Address - Street 1:401 N 9TH ST
Practice Address - Street 2:
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58501-4530
Practice Address - Country:US
Practice Address - Phone:701-530-6050
Practice Address - Fax:701-530-6417
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-17
Last Update Date:2017-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
ND9953336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2166898OtherPK
ND1469864Medicaid