1053498923 NPI number — PCA VENTURES OF COLORADO LLC

Table of content: (NPI 1053498923)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053498923 NPI number — PCA VENTURES OF COLORADO LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PCA VENTURES OF COLORADO 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:
HAYS MARKET 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:
1053498923
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/25/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 88
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JOHNSTOWN
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
80534-0088
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
201 JOHNSTOWN CENTER DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JOHNSTOWN
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
80534-9073
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
970-587-1128
Provider Business Practice Location Address Fax Number:
970-587-1139
Provider Enumeration Date:
10/31/2006

Additional Information

Authorized Official

Authorized Official Last Name:
RAMSEY
Authorized Official First Name:
STEVE
Authorized Official Middle Name:
Authorized Official Title or Position:
PHCY MGR
Authorized Official Telephone Number:
970-587-1128

Provider Taxonomy Codes

  • Taxonomy code: 3336C0003X , with the licence number:  609 , 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: 45785562 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0619481 . This is a "OTHER ID NUMBER" identifier . This identifiers is of the category "OTHER".




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