Provider Demographics
NPI:1023006038
Name:ESTES PARK PHARMACY INC
Entity Type:Organization
Organization Name:ESTES PARK PHARMACY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:RANDALL
Authorized Official - Last Name:JOENS
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:970-586-3366
Mailing Address - Street 1:600 S SAINT VRAIN AVE
Mailing Address - Street 2:UNIT 1
Mailing Address - City:ESTES PARK
Mailing Address - State:CO
Mailing Address - Zip Code:80517-7488
Mailing Address - Country:US
Mailing Address - Phone:970-586-3366
Mailing Address - Fax:970-586-0225
Practice Address - Street 1:600 S SAINT VRAIN AVE
Practice Address - Street 2:UNIT 1
Practice Address - City:ESTES PARK
Practice Address - State:CO
Practice Address - Zip Code:80517-7488
Practice Address - Country:US
Practice Address - Phone:970-586-3366
Practice Address - Fax:970-586-0225
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-12
Last Update Date:2014-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO39-2333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
0612007OtherNABP
CO03392008Medicaid
CO5865990001Medicare NSC