Basic Information
| Provider Information | |||||||||
| NPI: | 1447315627 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DAVITA PHARMACY COLORADO, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | COLORADO SPRINGS HEALTH PARTNERS PHARMACY LLC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2 S CASCADE AVE | ||||||||
| Address2: | SUITE 140 | ||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809031653 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195382900 | ||||||||
| FaxNumber: | 7195382987 | ||||||||
| Practice Location | |||||||||
| Address1: | 1633 MEDICAL CENTER POINT | ||||||||
| Address2: | |||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 80907 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7196332762 | ||||||||
| FaxNumber: | 7155759406 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/27/2006 | ||||||||
| LastUpdateDate: | 03/15/2017 | ||||||||
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| AuthorizedOfficialLastName: | HILGER | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
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| AuthorizedOfficialTitleorPosition: | CHIEF ACCOUNTING OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 2539730777 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 333600000X | N | Suppliers | Pharmacy | 3336C0003X | PDO0240000008 | CO | Y | Suppliers | Pharmacy | Community/Retail Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 91886872 | 05 | CO | MEDICAID | 2150668 | 01 | PK | OTHER | 06085288 | 05 | CO | MEDICAID |