1104173756 NPI number — DR. KATHERINE SUZANNE KLOCKAU PHARM.D.

Table of content: DR. KATHERINE SUZANNE KLOCKAU PHARM.D. (NPI 1104173756)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104173756 NPI number — DR. KATHERINE SUZANNE KLOCKAU PHARM.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KLOCKAU
Provider First Name:
KATHERINE
Provider Middle Name:
SUZANNE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PHARM.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
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:
1104173756
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/13/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
40 COUNTY ROAD #804
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FRASER
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
80442-0218
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
970-726-6920
Provider Business Mailing Address Fax Number:
970-726-6836

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
40 COUNTY ROAD
Provider Second Line Business Practice Location Address:
#804
Provider Business Practice Location Address City Name:
FRASER
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
80442-0218
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
970-726-6920
Provider Business Practice Location Address Fax Number:
970-726-6836
Provider Enumeration Date:
08/13/2012

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 183500000X , with the licence number:  19540 , 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)





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