Provider Demographics
NPI:1114641768
Name:TA, DARWIN
Entity Type:Individual
Prefix:
First Name:DARWIN
Middle Name:
Last Name:TA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3325 28TH ST
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80301-1440
Mailing Address - Country:US
Mailing Address - Phone:303-938-9284
Mailing Address - Fax:
Practice Address - Street 1:3325 28TH ST
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80301-1440
Practice Address - Country:US
Practice Address - Phone:303-938-9284
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-28
Last Update Date:2022-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0024232183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist