Provider Demographics
NPI:1497211379
Name:SELAH MOUNTAIN PHARMACY LLC
Entity Type:Organization
Organization Name:SELAH MOUNTAIN PHARMACY LLC
Other - Org Name:SELAH MOUNTAIN PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:KUTZKO
Authorized Official - Suffix:
Authorized Official - Credentials:PHARM D
Authorized Official - Phone:941-321-8067
Mailing Address - Street 1:PO BOX 5949
Mailing Address - Street 2:
Mailing Address - City:PAGOSA SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:81147-5949
Mailing Address - Country:US
Mailing Address - Phone:970-264-0126
Mailing Address - Fax:970-507-6111
Practice Address - Street 1:426 PAGOSA STREET
Practice Address - Street 2:
Practice Address - City:PAGOSA SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:81147
Practice Address - Country:US
Practice Address - Phone:970-264-0126
Practice Address - Fax:970-507-6111
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-02-15
Last Update Date:2021-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO1497211379Medicaid