Provider Demographics
NPI:1033532387
Name:EXEMPLA GOOD SAMARITAN OUTPATIENT PHARMACY
Entity Type:Organization
Organization Name:EXEMPLA GOOD SAMARITAN OUTPATIENT PHARMACY
Other - Org Name:EXEMPLA GOOD SAMARITAN MEDICAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CLINICAL PHARMACIST
Authorized Official - Prefix:DR
Authorized Official - First Name:DOUG
Authorized Official - Middle Name:
Authorized Official - Last Name:MALCOLM
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:303-689-4996
Mailing Address - Street 1:200 EXEMPLA CIR
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:CO
Mailing Address - Zip Code:80026-3370
Mailing Address - Country:US
Mailing Address - Phone:303-689-6121
Mailing Address - Fax:
Practice Address - Street 1:200 EXEMPLA CIR
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:CO
Practice Address - Zip Code:80026-3370
Practice Address - Country:US
Practice Address - Phone:303-689-6121
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-22
Last Update Date:2014-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO5783336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO07856539Medicaid
CO0619265OtherNCPDP PROVIDER ID