MEDICARE: HERITAGE PHARMACY GROUP 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	3336C0003X	Community/Retail Pharmacy

General Provider Information

NPI Number	:	1720576085
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HERITAGE PHARMACY GROUP LLC

Provider Business Mailing Address
First Line	:	10099 WEDDINGTON RD EXT, STE 120
Second Line	:
City	:	CONCORD
State	:	NC
Zip	:	28027
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	10099 WEDDINGTON RD EXT, STE 120
Second Line	:	STE 120
City	:	CONCORD
State	:	NC
Zip	:	28027
Country	:	US
Telephone Number	:	432-553-0051
Fax Number	:

Authorized Official
Title or Position	:	MANAGING MEMBER/OWNER
Name	:	RYAN DELVAUX
Credential	:
Telephone Number	:	631-374-1911

Provider Enumeration Date	:	04/23/2018
Last Update Date	:	01/16/2026

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Directions to “HERITAGE PHARMACY GROUP LLC ” Practice Location

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