1043652654 NPI number — PAGOSA HEALTH

Table of content: (NPI 1043652654)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1043652654 NPI number — PAGOSA HEALTH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PAGOSA HEALTH
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:
PAGOSA HEALTH
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:
1043652654
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/24/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
62 DOUGHTY RD STE 4
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAWRENCEBURG
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
47025-2951
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
888-821-9982
Provider Business Mailing Address Fax Number:
800-218-8256

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
62 DOUGHTY RD STE 4
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAWRENCEBURG
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
47025-2951
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
888-821-9982
Provider Business Practice Location Address Fax Number:
800-218-8256
Provider Enumeration Date:
07/24/2013

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
KOEHLER
Authorized Official First Name:
RONALD
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR OF PHARMACY OPERATION
Authorized Official Telephone Number:
859-638-2795

Provider Taxonomy Codes

  • Taxonomy code: 333600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336M0002X , with the licence number: 60006342A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 3336S0011X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 2141276 . This is a "PK" identifier . This identifiers is of the category "OTHER".