1497918221 NPI number — PHARMACA INTEGRATIVE PHARMACY

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497918221 NPI number — PHARMACA INTEGRATIVE PHARMACY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PHARMACA INTEGRATIVE PHARMACY
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:
1497918221
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/21/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4940 PEARL EAST CIR
Provider Second Line Business Mailing Address:
SUITE 301
Provider Business Mailing Address City Name:
BOULDER
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
80301-2489
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
303-442-2304
Provider Business Mailing Address Fax Number:
303-442-4605

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8650 GENESEE AVE
Provider Second Line Business Practice Location Address:
STE 100
Provider Business Practice Location Address City Name:
SAN DIEGO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92122-1134
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
858-362-5359
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/02/2008

Additional Information

Authorized Official

Authorized Official Last Name:
KRUTECK
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
Authorized Official Title or Position:
CFO
Authorized Official Telephone Number:
303-867-3163

Provider Taxonomy Codes

  • Taxonomy code: 3336C0003X , with the licence number:  PHY 49112 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 5630834 . This is a "NCPDP PROVIDER IDENTIFICATION NUMBER" identifier . This identifiers is of the category "OTHER".




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