Basic Information
| Provider Information | |||||||||
| NPI: | 1750035440 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SUMMIT COMMUNITY CARE CLINIC, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | MOUNTAIN CARES PHARMACY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 4337 | ||||||||
| Address2: | |||||||||
| City: | FRISCO | ||||||||
| State: | CO | ||||||||
| PostalCode: | 804434337 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | |||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 360 PEAK ONE DR STE 100A | ||||||||
| Address2: | |||||||||
| City: | FRISCO | ||||||||
| State: | CO | ||||||||
| PostalCode: | 804435948 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9706684040 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/10/2022 | ||||||||
| LastUpdateDate: | 02/11/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BYRD | ||||||||
| AuthorizedOfficialFirstName: | DAVE | ||||||||
| AuthorizedOfficialMiddleName: | ANDREW | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 9706684040 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SUMMIT COMMUNITY CARE CLINIC, INC. | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 02/11/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 333600000X | N | Suppliers | Pharmacy | 3336C0003X | Y | Suppliers | Pharmacy | Community/Retail Pharmacy |
No ID Information.