Provider Demographics
NPI:1467580720
Name:HIGH PLAINS MEDICAL LLC
Entity Type:Organization
Organization Name:HIGH PLAINS MEDICAL LLC
Other - Org Name:WB DRUG
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CJ
Authorized Official - Middle Name:
Authorized Official - Last Name:SHOVLIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:970-353-3316
Mailing Address - Street 1:PO BOX 1809
Mailing Address - Street 2:
Mailing Address - City:GREELEY
Mailing Address - State:CO
Mailing Address - Zip Code:80632-1809
Mailing Address - Country:US
Mailing Address - Phone:970-353-3316
Mailing Address - Fax:970-353-3316
Practice Address - Street 1:314 14TH ST
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:CO
Practice Address - Zip Code:80807-1608
Practice Address - Country:US
Practice Address - Phone:719-346-8851
Practice Address - Fax:719-346-7302
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-01
Last Update Date:2020-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X, 3336L0003X
CO1500000033336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO64476227Medicaid
0601991OtherNCPDP PROVIDER IDENTIFICATION NUMBER
6314750001Medicare NSC