Healthcare Provider Details

I. General information

NPI: 1982919130
Provider Name (Legal Business Name): HERITAGE PHARMACY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/12/2010
Last Update Date: 01/14/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1309 S MAIN ST
KINGFISHER OK
73750-4402
US

IV. Provider business mailing address

PO BOX 896
KINGFISHER OK
73750-0896
US

V. Phone/Fax

Practice location:
  • Phone: 405-375-6300
  • Fax: 405-375-6340
Mailing address:
  • Phone: 405-375-6300
  • Fax: 405-375-6340

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number54-5587
License Number StateOK

VIII. Authorized Official

Name: DENNIS SATCHELL
Title or Position: PHARMACIST/OWNER
Credential:
Phone: 405-368-6805