Provider Demographics
NPI:1891771747
Name:HEARTLAND PHARMACY - BOISE
Entity Type:Organization
Organization Name:HEARTLAND PHARMACY - BOISE
Other - Org Name:HEARTLAND PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CORPORATE DME SUPPORT SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:HEATHER
Authorized Official - Middle Name:
Authorized Official - Last Name:SHORTSLEEVE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-552-7677
Mailing Address - Street 1:1790 SABIN DR
Mailing Address - Street 2:
Mailing Address - City:AMMON
Mailing Address - State:ID
Mailing Address - Zip Code:83406-6747
Mailing Address - Country:US
Mailing Address - Phone:208-497-3575
Mailing Address - Fax:208-552-2103
Practice Address - Street 1:8455 W EMERALD ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-8306
Practice Address - Country:US
Practice Address - Phone:208-323-0067
Practice Address - Fax:208-323-5954
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-21
Last Update Date:2021-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID1680CP183500000X, 333600000X, 3336L0003X
ID1679LS332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
No333600000XSuppliersPharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID805127900Medicaid
ID805126600OtherMEDICAID DME
OR500600675Medicaid
OR500600675Medicaid