Provider Demographics
NPI:1124359765
Name:RANGELY DISTRCT HOSPITAL
Entity Type:Organization
Organization Name:RANGELY DISTRCT HOSPITAL
Other - Org Name:RANGELY PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:KYLE
Authorized Official - Middle Name:
Authorized Official - Last Name:WREN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:970-675-5011
Mailing Address - Street 1:225 EAGLE CREST DR
Mailing Address - Street 2:
Mailing Address - City:RANGELY
Mailing Address - State:CO
Mailing Address - Zip Code:81648-3105
Mailing Address - Country:US
Mailing Address - Phone:970-675-5011
Mailing Address - Fax:970-675-5224
Practice Address - Street 1:225 EAGLE CREST DR
Practice Address - Street 2:
Practice Address - City:RANGELY
Practice Address - State:CO
Practice Address - Zip Code:81648-3105
Practice Address - Country:US
Practice Address - Phone:970-675-2169
Practice Address - Fax:970-675-2160
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-21
Last Update Date:2021-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336L0003X
CO7933336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2123530OtherPK
CO80489061Medicaid