Provider Demographics
NPI:1104964840
Name:HERITAGE COMPOUNDING PHARMACY
Entity type:Organization
Organization Name:HERITAGE COMPOUNDING PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARM. D.
Authorized Official - Prefix:
Authorized Official - First Name:ESTHER
Authorized Official - Middle Name:
Authorized Official - Last Name:KIM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:714-579-1636
Mailing Address - Street 1:2903 SATURN ST STE A
Mailing Address - Street 2:
Mailing Address - City:BREA
Mailing Address - State:CA
Mailing Address - Zip Code:92821-6259
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2903 SATURN ST STE A
Practice Address - Street 2:
Practice Address - City:BREA
Practice Address - State:CA
Practice Address - Zip Code:92821-6259
Practice Address - Country:US
Practice Address - Phone:714-579-1636
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPHY470983336C0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0004XSuppliersPharmacyCompounding Pharmacy