Provider Demographics
NPI:1992203970
Name:HEIMDOLL HOLDINGS INC
Entity Type:Organization
Organization Name:HEIMDOLL HOLDINGS INC
Other - Org Name:RIVERTOWN COMPOUNDING PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:RPH
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:
Authorized Official - Last Name:HEIM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:616-828-8565
Mailing Address - Street 1:4365 CANAL AVE SW STE N
Mailing Address - Street 2:SUITE N
Mailing Address - City:GRANDVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:49418-2697
Mailing Address - Country:US
Mailing Address - Phone:616-723-9391
Mailing Address - Fax:616-288-9870
Practice Address - Street 1:4365 CANAL AVE SW STE N
Practice Address - Street 2:SUITE N
Practice Address - City:GRANDVILLE
Practice Address - State:MI
Practice Address - Zip Code:49418-2697
Practice Address - Country:US
Practice Address - Phone:616-723-9391
Practice Address - Fax:616-288-9870
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-25
Last Update Date:2018-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0003X
MI53010113133336C0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0004XSuppliersPharmacyCompounding Pharmacy
No333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2175505OtherPK