Healthcare Provider Details

I. General information

NPI: 1790866010
Provider Name (Legal Business Name): SOUTH HERO PHARMACY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/17/2006
Last Update Date: 09/04/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

334 US ROUTE 2
SOUTH HERO VT
05486
US

IV. Provider business mailing address

PO BOX 277 334 US ROUTE 2
SOUTH HERO VT
05486
US

V. Phone/Fax

Practice location:
  • Phone: 802-372-5377
  • Fax: 802-372-5638
Mailing address:
  • Phone: 802-372-5377
  • Fax: 802-372-5638

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number0380003129
License Number StateVT
# 3
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: AUDREY MCGREGOR REARDON
Title or Position: PRES
Credential:
Phone: 802-655-3544