1982769030 NPI number — HEALTHY DRUGSTORE, INC

Table of content: (NPI 1982769030)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1982769030 NPI number — HEALTHY DRUGSTORE, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HEALTHY DRUGSTORE, 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:
RIVERGATE 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:
1982769030
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:
PO BOX 4029
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DURANGO
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
81302-4029
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
970-375-7711
Provider Business Mailing Address Fax Number:
970-375-7722

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
575 RIVERGATE LANE
Provider Second Line Business Practice Location Address:
SUITE 111
Provider Business Practice Location Address City Name:
DURANGO
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
81301-7487
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
970-375-7711
Provider Business Practice Location Address Fax Number:
970-375-7722
Provider Enumeration Date:
12/27/2006

Additional Information

Authorized Official

Authorized Official Last Name:
NOCITA
Authorized Official First Name:
DEBBIE
Authorized Official Middle Name:
J
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
970-375-7711

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X , with the licence number:  592 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X , with the licence number: 592 , 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: 26784068 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0619342 . This is a "NCPDP" identifier , issued by the state of ( CO ) . This identifiers is of the category "OTHER".




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