Healthcare Provider Details

I. General information

NPI: 1104964840
Provider Name (Legal Business Name): HERITAGE COMPOUNDING PHARMACY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/02/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2903 SATURN ST STE A
BREA CA
92821-6259
US

IV. Provider business mailing address

2903 SATURN ST STE A
BREA CA
92821-6259
US

V. Phone/Fax

Practice location:
  • Phone: 714-579-1636
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License NumberPHY47098
License Number StateCA

VIII. Authorized Official

Name: ESTHER KIM
Title or Position: PHARM. D.
Credential:
Phone: 714-579-1636