Provider Demographics
NPI:1306831995
Name:COLORADO PHARMACY LLC
Entity Type:Organization
Organization Name:COLORADO PHARMACY LLC
Other - Org Name:COLORADO PHARMACY WEST
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JANE
Authorized Official - Middle Name:
Authorized Official - Last Name:NICHOLS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:303-863-7644
Mailing Address - Street 1:PO BOX 300127
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80203-0127
Mailing Address - Country:US
Mailing Address - Phone:303-863-7644
Mailing Address - Fax:303-863-7656
Practice Address - Street 1:2490 W 26TH AVE
Practice Address - Street 2:SUITE 300A
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80211-5314
Practice Address - Country:US
Practice Address - Phone:303-458-6200
Practice Address - Fax:303-458-6203
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO615183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO48985848Medicaid