1376000950 NPI number — ARVADA PHARMACY AND MEDICAL SUPPLY

Table of content: DR. ISAAC CHARLES SEBOURN DDS (NPI 1013264704)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1376000950 NPI number — ARVADA PHARMACY AND MEDICAL SUPPLY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ARVADA PHARMACY AND MEDICAL SUPPLY
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:
Provider Other Organization Name Type Code:
6
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:
1376000950
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10382 RALSTON RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ARVADA
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
80004-5860
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
720-707-2444
Provider Business Mailing Address Fax Number:
720-707-2400

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10382 RALSTON RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ARVADA
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
80004-5860
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
720-707-2444
Provider Business Practice Location Address Fax Number:
720-707-2400
Provider Enumeration Date:
03/01/2019

Additional Information

Authorized Official

Authorized Official Last Name:
UKHNOVSKY
Authorized Official First Name:
JULIA
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
720-707-2444

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336S0011X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 20206000260 . This is a "COLORADO STATE DME LICENSE" identifier , issued by the state of ( CO ) . This identifiers is of the category "OTHER".
  • Identifier: 0626599 . This is a "NCPDP" identifier . This identifiers is of the category "OTHER".
  • Identifier: 9000171561 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 38356159 . This is a "COLORADO SALEX TAX LICENSE" identifier , issued by the state of ( CO ) . This identifiers is of the category "OTHER".
  • Identifier: PDO.1680000194 . This is a "STATE OF COLORADO BOARD OF PHARMACY" identifier , issued by the state of ( CO ) . This identifiers is of the category "OTHER".
  • Identifier: 87071000 . This is a "CITY OF ARVADA" identifier , issued by the state of ( CO ) . This identifiers is of the category "OTHER".




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