Provider Demographics
NPI:1346795903
Name:KING SOOPERS
Entity Type:Organization
Organization Name:KING SOOPERS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:IYOBOSA
Authorized Official - Middle Name:SANDRA
Authorized Official - Last Name:OSA-EDOH
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:314-757-4031
Mailing Address - Street 1:65 TEJON ST
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80223-1221
Mailing Address - Country:US
Mailing Address - Phone:314-757-4031
Mailing Address - Fax:
Practice Address - Street 1:65 TEJON ST
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80223-1221
Practice Address - Country:US
Practice Address - Phone:314-757-4031
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-23
Last Update Date:2016-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0021435183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty