1295917938 NPI number — STATE OF COLORADO

Table of content: (NPI 1295917938)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1295917938 NPI number — STATE OF COLORADO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
STATE OF COLORADO
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:
1295917938
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/25/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1600 W 24TH ST
Provider Second Line Business Mailing Address:
BLDG 16
Provider Business Mailing Address City Name:
PUEBLO
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
81003-1411
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
719-583-5819
Provider Business Mailing Address Fax Number:
719-583-5825

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1600 W 24TH ST
Provider Second Line Business Practice Location Address:
BLDG 16
Provider Business Practice Location Address City Name:
PUEBLO
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
81003-1411
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
719-583-5819
Provider Business Practice Location Address Fax Number:
719-583-5825
Provider Enumeration Date:
12/05/2007

Additional Information

Authorized Official

Authorized Official Last Name:
WILSON
Authorized Official First Name:
ERIKA
Authorized Official Middle Name:
Authorized Official Title or Position:
PHARMACY MANAGER
Authorized Official Telephone Number:
720-319-0445

Provider Taxonomy Codes

  • Taxonomy code: 3336I0012X , with the licence number:  990000001 , 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: 0617552 . This is a "NCPDP PROVIDER IDENTIFICATION NUMBER" identifier . This identifiers is of the category "OTHER".




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