Provider Demographics
NPI:1396037867
Name:RIO GRANDE PHARMACY LLC
Entity Type:Organization
Organization Name:RIO GRANDE PHARMACY LLC
Other - Org Name:RIO GRANDE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PIC
Authorized Official - Prefix:
Authorized Official - First Name:ANGELIA
Authorized Official - Middle Name:
Authorized Official - Last Name:CAMPBELL
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:719-657-3513
Mailing Address - Street 1:650 GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:DEL NORTE
Mailing Address - State:CO
Mailing Address - Zip Code:81132-2206
Mailing Address - Country:US
Mailing Address - Phone:719-657-3513
Mailing Address - Fax:719-657-3845
Practice Address - Street 1:650 GRAND AVE
Practice Address - Street 2:
Practice Address - City:DEL NORTE
Practice Address - State:CO
Practice Address - Zip Code:81132-2206
Practice Address - Country:US
Practice Address - Phone:719-657-3513
Practice Address - Fax:719-657-3845
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-03
Last Update Date:2017-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2800000013336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2130147OtherPK
CO35078243Medicaid