Provider Demographics
NPI:1790866010
Name:SOUTH HERO PHARMACY LLC
Entity Type:Organization
Organization Name:SOUTH HERO PHARMACY LLC
Other - Org Name:SOUTH HERO PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRES
Authorized Official - Prefix:
Authorized Official - First Name:AUDREY
Authorized Official - Middle Name:
Authorized Official - Last Name:MCGREGOR REARDON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:802-655-3544
Mailing Address - Street 1:PO BOX 277
Mailing Address - Street 2:334 US ROUTE 2
Mailing Address - City:SOUTH HERO
Mailing Address - State:VT
Mailing Address - Zip Code:05486
Mailing Address - Country:US
Mailing Address - Phone:802-372-5377
Mailing Address - Fax:802-372-5638
Practice Address - Street 1:334 US ROUTE 2
Practice Address - Street 2:
Practice Address - City:SOUTH HERO
Practice Address - State:VT
Practice Address - Zip Code:05486
Practice Address - Country:US
Practice Address - Phone:802-372-5377
Practice Address - Fax:802-372-5638
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-17
Last Update Date:2014-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0003X
VT03800031293336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
4703129OtherOTHER ID NUMBER
VT0007138Medicaid
VT0007138Medicaid