Healthcare Provider Details

I. General information

NPI: 1932122918
Provider Name (Legal Business Name): WARROAD HERITAGE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/25/2006
Last Update Date: 10/03/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

321 LAKE ST NE
WARROAD MN
56763-2305
US

IV. Provider business mailing address

PO BOX M
WARROAD MN
56763-0640
US

V. Phone/Fax

Practice location:
  • Phone: 218-386-1088
  • Fax: 218-386-1780
Mailing address:
  • Phone: 218-386-1088
  • Fax: 218-386-1780

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code3336M0002X
TaxonomyMail Order Pharmacy
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number200560
License Number StateMN

VIII. Authorized Official

Name: JEANNE ERICKSON
Title or Position: OWNER MGR
Credential: RPH
Phone: 218-386-1088