1124262563 NPI number — GJ COMPOUNDING LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124262563 NPI number — GJ COMPOUNDING LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GJ COMPOUNDING LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
WESTERN COLORADO SPECIALTY PHARMACY
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1124262563
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/10/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2472 PATTERSON RD.
Provider Second Line Business Mailing Address:
STE. 12
Provider Business Mailing Address City Name:
GRAND JUNCTION
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
81505
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
970-243-5050
Provider Business Mailing Address Fax Number:
970-243-5110

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2472 PATTERSON RD.
Provider Second Line Business Practice Location Address:
STE. 12
Provider Business Practice Location Address City Name:
GRAND JUNCTION
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
81505
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
970-243-5050
Provider Business Practice Location Address Fax Number:
970-243-5110
Provider Enumeration Date:
04/29/2009

Additional Information

Authorized Official

Authorized Official Last Name:
FRAZER
Authorized Official First Name:
ERIC
Authorized Official Middle Name:
MICHAEL
Authorized Official Title or Position:
OWNER/PIC
Authorized Official Telephone Number:
970-243-5050

Provider Taxonomy Codes

  • Taxonomy code: 3336C0004X , with the licence number:  763 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0621234 . This is a "NCPDP PROVIDER IDENTIFICATION NUMBER" identifier . This identifiers is of the category "OTHER".




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