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General NPI Number Information
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NPI Number | 1255445243
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Entity Type | Organization
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Legal Business Name | HERITAGE PHARMACY INCORPORATED
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Dates
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Enumeration Date | 08/18/2006
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Last Update Date | 04/24/2019
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Provider Practice Location Address
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Address Line | 621 N. HAMPTON RD STE. 108
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City | DESOTO
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State | TX
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Zip | 75115
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Country | US
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Telephone | 469-747-3171
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Fax | 469-747-3172
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Provider Business Mailing Address
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Address Line | 621 N. HAMPTON RD STE. 108
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City | DESOTO
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State | TX
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Zip | 75115
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Country | US
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Telephone | 469-747-3171
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Fax | 469-747-3172
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Authorized Official
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Title or Position | MANAGING OFFICER
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Name | MR. NAIBON D. MOORE
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Credential |
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Telephone | 313-819-7339
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 3336C0003X
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Taxonomy Name | Community/Retail Pharmacy
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License Number | 23998
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License Number State | TX
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