MEDICARE: HEARTLAND PHARMACY 2 LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	333600000X	Pharmacy
2	3336C0004X	Compounding Pharmacy
3	332B00000X	Durable Medical Equipment & Medical Supplies
4	3336C0003X	Community/Retail Pharmacy	022243550	OH

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2137123	OTHER		PK
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1083964787
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HEARTLAND PHARMACY 2 LLC

Provider Business Mailing Address
First Line	:	2749 W ALEX BELL RD
Second Line	:
City	:	MORAINE
State	:	OH
Zip	:	45459-1123
Country	:	US
Telephone Number	:	937-395-3690
Fax Number	:	937-395-3694

Provider Business Practice Location Address
First Line	:	2749 W ALEX BELL RD
Second Line	:
City	:	MORAINE
State	:	OH
Zip	:	45459-1123
Country	:	US
Telephone Number	:	937-395-3690
Fax Number	:	937-395-3694

Authorized Official
Title or Position	:	OWNER
Name	:	KINDY GHUSSIN
Credential	:	RPH
Telephone Number	:	937-829-1012

Provider Enumeration Date	:	09/11/2012
Last Update Date	:	02/25/2015

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Directions to “HEARTLAND PHARMACY 2 LLC ” Practice Location

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