Provider Demographics
NPI:1437223955
Name:JERRY P ARCHULETA SANLUIS PHARMACY LLC
Entity Type:Organization
Organization Name:JERRY P ARCHULETA SANLUIS PHARMACY LLC
Other - Org Name:SAN LUIS VALLEY PHARMACY LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:
Authorized Official - Last Name:ARCHULEKA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:719-587-3039
Mailing Address - Street 1:2431 MAIN ST
Mailing Address - Street 2:STE 5
Mailing Address - City:ALAMOSA
Mailing Address - State:CO
Mailing Address - Zip Code:81101-4273
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2431 MAIN ST
Practice Address - Street 2:STE 5
Practice Address - City:ALAMOSA
Practice Address - State:CO
Practice Address - Zip Code:81101-4273
Practice Address - Country:US
Practice Address - Phone:719-587-3039
Practice Address - Fax:719-587-2164
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-17
Last Update Date:2008-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 3336C0003X, 3336M0002X
COPDO20000022333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336M0002XSuppliersPharmacyMail Order Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
0618326OtherOTHER ID NUMBER-COMMERCIAL NUMBER
CO4856160001Medicare NSC