Provider Demographics
NPI:1093120305
Name:CHINOOK HEALTHCARE INC
Entity Type:Organization
Organization Name:CHINOOK HEALTHCARE INC
Other - Org Name:CHINOOK HEALTHCARE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:TYSON
Authorized Official - Middle Name:
Authorized Official - Last Name:HODGE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:303-880-2007
Mailing Address - Street 1:275 WANEKA PKWY
Mailing Address - Street 2:STE. 10
Mailing Address - City:LAFAYETTE
Mailing Address - State:CO
Mailing Address - Zip Code:80026-8873
Mailing Address - Country:US
Mailing Address - Phone:720-458-4887
Mailing Address - Fax:720-465-9312
Practice Address - Street 1:275 WANEKA PKWY
Practice Address - Street 2:STE. 10
Practice Address - City:LAFAYETTE
Practice Address - State:CO
Practice Address - Zip Code:80026-8873
Practice Address - Country:US
Practice Address - Phone:720-458-4887
Practice Address - Fax:720-465-9312
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-25
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X, 3336C0004X
COPDO.16800000583336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Multi-Specialty
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2146966OtherPK
CO54930022Medicaid