Provider Demographics
NPI:1043652654
Name:PAGOSA HEALTH
Entity Type:Organization
Organization Name:PAGOSA HEALTH
Other - Org Name:PAGOSA HEALTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF PHARMACY OPERATION
Authorized Official - Prefix:
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:
Authorized Official - Last Name:KOEHLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:859-638-2795
Mailing Address - Street 1:62 DOUGHTY RD STE 4
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEBURG
Mailing Address - State:IN
Mailing Address - Zip Code:47025-2951
Mailing Address - Country:US
Mailing Address - Phone:888-821-9982
Mailing Address - Fax:800-218-8256
Practice Address - Street 1:62 DOUGHTY RD STE 4
Practice Address - Street 2:
Practice Address - City:LAWRENCEBURG
Practice Address - State:IN
Practice Address - Zip Code:47025-2951
Practice Address - Country:US
Practice Address - Phone:888-821-9982
Practice Address - Fax:800-218-8256
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-24
Last Update Date:2013-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336S0011X
IN60006342A3336M0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336M0002XSuppliersPharmacyMail Order Pharmacy
No333600000XSuppliersPharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2141276OtherPK