Provider Demographics
NPI:1780775700
Name:HERITAGE PHARMACY, INC.
Entity type:Organization
Organization Name:HERITAGE PHARMACY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT OF OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:HENRY
Authorized Official - Middle Name:B
Authorized Official - Last Name:FULGHAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:251-343-9600
Mailing Address - Street 1:6207 COTTAGE HILL RD
Mailing Address - Street 2:SUITE G
Mailing Address - City:MOBILE
Mailing Address - State:AL
Mailing Address - Zip Code:36609-3113
Mailing Address - Country:US
Mailing Address - Phone:251-666-0250
Mailing Address - Fax:251-660-1451
Practice Address - Street 1:3151 KNOLLWOOD DR
Practice Address - Street 2:
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36693-2753
Practice Address - Country:US
Practice Address - Phone:251-661-7600
Practice Address - Fax:251-602-9160
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL200374333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
11121240001Medicare ID - Type Unspecified