1275178725 NPI number — OBINNA MICHAEL VAN-LARE PHARM.D.

Table of content: OBINNA MICHAEL VAN-LARE PHARM.D. (NPI 1275178725)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1275178725 NPI number — OBINNA MICHAEL VAN-LARE PHARM.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
VAN-LARE
Provider First Name:
OBINNA
Provider Middle Name:
MICHAEL
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PHARM.D.
Provider Gender Code:
M

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:
1275178725
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/21/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7720 S BROADWAY STE 100
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LITTLETON
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
80122-2624
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
720-627-6123
Provider Business Mailing Address Fax Number:
720-627-6129

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7720 S BROADWAY STE 100
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LITTLETON
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
80122-2624
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
720-627-6123
Provider Business Practice Location Address Fax Number:
720-627-6129
Provider Enumeration Date:
11/07/2019

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:  PHA.0022722 , 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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