Basic Information
| Provider Information | |||||||||
| NPI: | 1992908743 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | AMERITA, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6912 S QUENTIN ST STE 50 | ||||||||
| Address2: | |||||||||
| City: | CENTENNIAL | ||||||||
| State: | CO | ||||||||
| PostalCode: | 801124531 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7202825325 | ||||||||
| FaxNumber: | 8776760493 | ||||||||
| Practice Location | |||||||||
| Address1: | 2270 GARDEN OF THE GODS RD | ||||||||
| Address2: | STE 102 | ||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809079438 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195703100 | ||||||||
| FaxNumber: | 7195703125 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/08/2007 | ||||||||
| LastUpdateDate: | 10/21/2022 | ||||||||
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| AuthorizedOfficialLastName: | IRIYE | ||||||||
| AuthorizedOfficialFirstName: | RICHARD | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7202822377 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 10/21/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | PDO-689 | CO | N | Suppliers | Durable Medical Equipment & Medical Supplies | 332BP3500X | PDO-689 | CO | N | Suppliers | Durable Medical Equipment & Medical Supplies | Parenteral & Enteral Nutrition | 3336H0001X | 689 | CO | Y | Suppliers | Pharmacy | Home Infusion Therapy Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | FA0322696 | 01 | DEA | OTHER | 0620345 | 01 | CO | NCPDP | OTHER | 80053246 | 05 | CO | MEDICAID | PDO-689 | 01 | CO | BOARD OF PHARMACY | OTHER |