Healthcare Provider Details

I. General information

NPI: 1891401535
Provider Name (Legal Business Name): HERITAGE PARK PHARMACY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/26/2023
Last Update Date: 01/26/2023
Certification Date: 01/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3032 AVENUE L
FORT MADISON IA
52627-3625
US

IV. Provider business mailing address

1221 S GEAR AVE
WEST BURLINGTON IA
52655-1679
US

V. Phone/Fax

Practice location:
  • Phone: 319-768-1000
  • Fax:
Mailing address:
  • Phone: 319-768-1000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: DR. MICHAEL JERRY MCCOY
Title or Position: PRESIDENT/CEO
Credential: MD
Phone: 319-768-3268