Provider Demographics
NPI:1780661751
Name:HERITAGE PARK PHARMACY INC
Entity Type:Organization
Organization Name:HERITAGE PARK PHARMACY INC
Other - Org Name:HERITAGE PARTNERS PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT AND CEO
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:JERRY
Authorized Official - Last Name:MCCOY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:197-683-2683
Mailing Address - Street 1:1225 S GEAR AVE STE 154
Mailing Address - Street 2:
Mailing Address - City:WEST BURLINGTON
Mailing Address - State:IA
Mailing Address - Zip Code:52655-1688
Mailing Address - Country:US
Mailing Address - Phone:319-768-3960
Mailing Address - Fax:319-768-3964
Practice Address - Street 1:1225 S GEAR AVE STE 154
Practice Address - Street 2:
Practice Address - City:WEST BURLINGTON
Practice Address - State:IA
Practice Address - Zip Code:52655-1688
Practice Address - Country:US
Practice Address - Phone:319-768-3960
Practice Address - Fax:319-768-3964
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-29
Last Update Date:2023-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA1060183500000X, 3336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
No3336L0003XSuppliersPharmacyLong Term Care PharmacyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0178301Medicaid
IA0178301Medicaid
IA0341550004Medicare ID - Type UnspecifiedMEDICARE NUMBER