MEDICARE: HEARTLAND PHARMACY LAKE PLACID

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	3336C0003X	Community/Retail Pharmacy	PH26570	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2138527	OTHER		PK
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1811233430
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HEARTLAND PHARMACY LAKE PLACID

Provider Business Mailing Address
First Line	:	342 E ROYAL PALM ST
Second Line	:
City	:	LAKE PLACID
State	:	FL
Zip	:	33852-5019
Country	:	US
Telephone Number	:	863-659-1780
Fax Number	:	863-659-1786

Provider Business Practice Location Address
First Line	:	342 E ROYAL PALM ST
Second Line	:
City	:	LAKE PLACID
State	:	FL
Zip	:	33852-5019
Country	:	US
Telephone Number	:	863-659-1780
Fax Number	:	863-659-1786

Authorized Official
Title or Position	:	OWNER/PRESIDENT
Name	:	CARIN BRALTS
Credential	:	PHARMD
Telephone Number	:	863-449-1006

Provider Enumeration Date	:	12/31/2012
Last Update Date	:	03/01/2017

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