Healthcare Provider Details

I. General information

NPI: 1033124672
Provider Name (Legal Business Name): HEARTLAND PHARMACY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/30/2006
Last Update Date: 04/07/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

170 BEECH ST STE 2
HARROGATE TN
37752-8514
US

IV. Provider business mailing address

170 BEECH ST SUITE 2
HARROGATE TN
37752-8251
US

V. Phone/Fax

Practice location:
  • Phone: 423-869-7790
  • Fax: 423-869-0702
Mailing address:
  • Phone: 423-869-7790
  • Fax: 423-869-0702

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number1438
License Number StateTN

VIII. Authorized Official

Name: DETRA LEWIS
Title or Position: MANGR CO OWNR
Credential: PHARM D
Phone: 423-869-7790