Provider Demographics
NPI:1932122918
Name:WARROAD HERITAGE INC
Entity Type:Organization
Organization Name:WARROAD HERITAGE INC
Other - Org Name:WARROAD HERITAGE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER MGR
Authorized Official - Prefix:
Authorized Official - First Name:JEANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:ERICKSON
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:218-386-1088
Mailing Address - Street 1:PO BOX M
Mailing Address - Street 2:
Mailing Address - City:WARROAD
Mailing Address - State:MN
Mailing Address - Zip Code:56763-0640
Mailing Address - Country:US
Mailing Address - Phone:218-386-1088
Mailing Address - Fax:218-386-1780
Practice Address - Street 1:321 LAKE ST NE
Practice Address - Street 2:
Practice Address - City:WARROAD
Practice Address - State:MN
Practice Address - Zip Code:56763-2305
Practice Address - Country:US
Practice Address - Phone:218-386-1088
Practice Address - Fax:218-386-1780
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-25
Last Update Date:2011-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 3336L0003X, 3336M0002X
MN2005603336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No3336M0002XSuppliersPharmacyMail Order Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2412081OtherNCPDP PROVIDER IDENTIFICATION NUMBER
MN611760100Medicaid
0619370001Medicare NSC