Provider Demographics
NPI:1043862485
Name:PARK AVE APOTHECARY LLC
Entity Type:Organization
Organization Name:PARK AVE APOTHECARY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PATRICK
Authorized Official - Middle Name:
Authorized Official - Last Name:SCHEELS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:303-898-7183
Mailing Address - Street 1:2431 N UNION BLVD
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80909-1107
Mailing Address - Country:US
Mailing Address - Phone:719-630-3154
Mailing Address - Fax:719-630-1640
Practice Address - Street 1:2431 N UNION BLVD
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80909-1107
Practice Address - Country:US
Practice Address - Phone:719-630-3154
Practice Address - Fax:719-630-1640
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PARK AVE APOTHECARY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-07-16
Last Update Date:2019-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO03577319Medicaid
7599910001OtherPTAN
CO240000040OtherSTATE PHARMACY LICENSE