Provider Demographics
NPI:1811233430
Name:HEARTLAND PHARMACY LAKE PLACID
Entity Type:Organization
Organization Name:HEARTLAND PHARMACY LAKE PLACID
Other - Org Name:HEARTLAND PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CARIN
Authorized Official - Middle Name:
Authorized Official - Last Name:BRALTS
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:863-449-1006
Mailing Address - Street 1:342 E ROYAL PALM ST
Mailing Address - Street 2:
Mailing Address - City:LAKE PLACID
Mailing Address - State:FL
Mailing Address - Zip Code:33852-5019
Mailing Address - Country:US
Mailing Address - Phone:863-659-1780
Mailing Address - Fax:863-659-1786
Practice Address - Street 1:342 E ROYAL PALM ST
Practice Address - Street 2:
Practice Address - City:LAKE PLACID
Practice Address - State:FL
Practice Address - Zip Code:33852-5019
Practice Address - Country:US
Practice Address - Phone:863-659-1780
Practice Address - Fax:863-659-1786
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-31
Last Update Date:2017-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
FLPH265703336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2138527OtherPK
FL008053900Medicaid
FL6840910001Medicare NSC