Provider Demographics
NPI:1376813055
Name:RICUPERO, PETER
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:
Last Name:RICUPERO
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 1:4800 BASELINE RD
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80303-2699
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4800 BASELINE RD
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80303-2699
Practice Address - Country:US
Practice Address - Phone:303-499-1919
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-01-11
Last Update Date:2012-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO13915183500000X
CT4995183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist