1053673699 NPI number — COBIGRED INC

Table of content: (NPI 1053673699)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053673699 NPI number — COBIGRED INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COBIGRED INC
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:
HOMETOWN PHARMACY AND MEDICAL
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:
1053673699
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/15/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
824 E MAIN ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TRINIDAD
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
81082-2782
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
719-845-0069
Provider Business Mailing Address Fax Number:
719-846-8439

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
824 E MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TRINIDAD
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
81082-2782
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
719-845-0069
Provider Business Practice Location Address Fax Number:
719-846-8439
Provider Enumeration Date:
06/11/2012

Additional Information

Authorized Official

Authorized Official Last Name:
SCHEELS
Authorized Official First Name:
PATRICK
Authorized Official Middle Name:
Authorized Official Title or Position:
SECRETARY/OWNER
Authorized Official Telephone Number:
303-898-7183

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 333600000X , with the licence number: 557 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 3336C0003X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0004X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336L0003X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 0622755 . This is a "NCPDP" identifier , issued by the state of ( CO ) . This identifiers is of the category "OTHER".
  • Identifier: 2137541 . This is a "PK" identifier . This identifiers is of the category "OTHER".
  • Identifier: 59624574 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1053673699 . This is a "NPI" identifier , issued by the state of ( CO ) . This identifiers is of the category "OTHER".




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