Provider Demographics
NPI:1114080439
Name:PHARMACA INTEGRATIVE PHARMACY, INC.
Entity Type:Organization
Organization Name:PHARMACA INTEGRATIVE PHARMACY, INC.
Other - Org Name:MEDLY PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SVP PHARMACY SERVICES
Authorized Official - Prefix:
Authorized Official - First Name:ALISON
Authorized Official - Middle Name:
Authorized Official - Last Name:FARRELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:717-254-9011
Mailing Address - Street 1:7088 WINCHESTER CIR STE 100
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80301-3760
Mailing Address - Country:US
Mailing Address - Phone:303-442-2304
Mailing Address - Fax:303-867-4181
Practice Address - Street 1:530 W CORDOVA RD
Practice Address - Street 2:STE B
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505
Practice Address - Country:US
Practice Address - Phone:505-820-7467
Practice Address - Fax:505-820-7697
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-18
Last Update Date:2022-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
NMPHY26923336C0003X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
3211000OtherOTHER ID NUMBER
3211000OtherOTHER ID NUMBER