Basic Information
| Provider Information | |||||||||
| NPI: | 1144413865 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PRIMO ENTERPRISES INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | CHASE PHARMACY FLU SHOT PROGRAM | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 568 US HIGHWAY 36 | ||||||||
| Address2: | |||||||||
| City: | BYERS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 801039700 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3038229371 | ||||||||
| FaxNumber: | 3038229746 | ||||||||
| Practice Location | |||||||||
| Address1: | 568 US HIGHWAY 36 | ||||||||
| Address2: | |||||||||
| City: | BYERS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 801039700 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3038229371 | ||||||||
| FaxNumber: | 3038229746 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/27/2007 | ||||||||
| LastUpdateDate: | 02/11/2008 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | CHASE | ||||||||
| AuthorizedOfficialFirstName: | WILSON | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PHARMACIST | ||||||||
| AuthorizedOfficialTelephone: | 3038229371 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | R. PH. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 333600000X | 1120000001 | CO | Y | Suppliers | Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 03165008 | 05 | CO | MEDICAID |