Basic Information
| Provider Information | |||||||||
| NPI: | 1326564246 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COMMUNITY CLINICS AT MEMORIAL REGIONAL HEALTH | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | COMMUNITY PHARMACY AT MEMORIAL REGIONAL HEALTH | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 750 HOSPITAL LOOP | ||||||||
| Address2: | |||||||||
| City: | CRAIG | ||||||||
| State: | CO | ||||||||
| PostalCode: | 816258750 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9708249411 | ||||||||
| FaxNumber: | 9708263119 | ||||||||
| Practice Location | |||||||||
| Address1: | 750 HOSPITAL LOOP | ||||||||
| Address2: | |||||||||
| City: | CRAIG | ||||||||
| State: | CO | ||||||||
| PostalCode: | 816258750 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9708249411 | ||||||||
| FaxNumber: | 9708263119 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/22/2017 | ||||||||
| LastUpdateDate: | 05/27/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MILLER | ||||||||
| AuthorizedOfficialFirstName: | KYLE | ||||||||
| AuthorizedOfficialMiddleName: | ALAN | ||||||||
| AuthorizedOfficialTitleorPosition: | VP OF CLINICAL SERVICES | ||||||||
| AuthorizedOfficialTelephone: | 9708263107 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | PHARMD | ||||||||
| NPICertificationDate: | 05/27/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 333600000X | N | Suppliers | Pharmacy | 3336C0002X | N | Suppliers | Pharmacy | Clinic Pharmacy | 3336C0003X | PDO.1680000152 | CO | Y | Suppliers | Pharmacy | Community/Retail Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 9000156463 | 05 | CO | MEDICAID | 2171012 | 01 | PK | OTHER |