1780775700 NPI number — HERITAGE PHARMACY, INC.

Table of content: (NPI 1780775700)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1780775700 NPI number — HERITAGE PHARMACY, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HERITAGE PHARMACY, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1780775700
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6207 COTTAGE HILL RD
Provider Second Line Business Mailing Address:
SUITE G
Provider Business Mailing Address City Name:
MOBILE
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
36609-3113
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
251-666-0250
Provider Business Mailing Address Fax Number:
251-660-1451

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3151 KNOLLWOOD DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MOBILE
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
36693-2753
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
251-661-7600
Provider Business Practice Location Address Fax Number:
251-602-9160
Provider Enumeration Date:
09/27/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
FULGHAM
Authorized Official First Name:
HENRY
Authorized Official Middle Name:
B
Authorized Official Title or Position:
VICE PRESIDENT OF OPERATIONS
Authorized Official Telephone Number:
251-343-9600

Provider Taxonomy Codes

  • Taxonomy code: 333600000X , with the licence number:  200374 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)