Provider Demographics
NPI:1407907488
Name:OPERA HOUSE PHARMACY CO INC
Entity Type:Organization
Organization Name:OPERA HOUSE PHARMACY CO INC
Other - Org Name:OPERA HOUSE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:
Authorized Official - Last Name:VASQUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:719-384-2521
Mailing Address - Street 1:223 COLORADO AVE
Mailing Address - Street 2:PO BOX 377
Mailing Address - City:LA JUNTA
Mailing Address - State:CO
Mailing Address - Zip Code:81050-1517
Mailing Address - Country:US
Mailing Address - Phone:719-384-2521
Mailing Address - Fax:719-384-2523
Practice Address - Street 1:223 COLORADO AVE
Practice Address - Street 2:
Practice Address - City:LA JUNTA
Practice Address - State:CO
Practice Address - Zip Code:81050-1517
Practice Address - Country:US
Practice Address - Phone:719-384-2521
Practice Address - Fax:719-384-2523
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-16
Last Update Date:2016-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X
CO7200000073336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2000783OtherPK
CO03628500Medicaid
CO03628500Medicaid