Provider Demographics
NPI:1982919130
Name:HERITAGE PHARMACY LLC
Entity Type:Organization
Organization Name:HERITAGE PHARMACY LLC
Other - Org Name:HERITAGE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DENNIS
Authorized Official - Middle Name:
Authorized Official - Last Name:SATCHELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-368-6805
Mailing Address - Street 1:PO BOX 896
Mailing Address - Street 2:
Mailing Address - City:KINGFISHER
Mailing Address - State:OK
Mailing Address - Zip Code:73750-0896
Mailing Address - Country:US
Mailing Address - Phone:405-375-6300
Mailing Address - Fax:405-375-6340
Practice Address - Street 1:1309 S MAIN ST
Practice Address - Street 2:
Practice Address - City:KINGFISHER
Practice Address - State:OK
Practice Address - Zip Code:73750-4402
Practice Address - Country:US
Practice Address - Phone:405-375-6300
Practice Address - Fax:405-375-6340
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-12
Last Update Date:2015-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336L0003X
OK54-55873336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100235150AMedicaid
2126196OtherPK
6541910001Medicare NSC