Provider Demographics
NPI:1497214332
Name:WHEATRIDGE DRUG STORE LLC
Entity Type:Organization
Organization Name:WHEATRIDGE DRUG STORE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:WENDY
Authorized Official - Middle Name:
Authorized Official - Last Name:DILORENZO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:303-421-6111
Mailing Address - Street 1:6650 W 38TH AVE
Mailing Address - Street 2:
Mailing Address - City:WHEAT RIDGE
Mailing Address - State:CO
Mailing Address - Zip Code:80033-4906
Mailing Address - Country:US
Mailing Address - Phone:303-421-6111
Mailing Address - Fax:303-431-8320
Practice Address - Street 1:6650 W 38TH AVE
Practice Address - Street 2:
Practice Address - City:WHEAT RIDGE
Practice Address - State:CO
Practice Address - Zip Code:80033-4906
Practice Address - Country:US
Practice Address - Phone:303-421-6111
Practice Address - Fax:303-431-8320
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-03-19
Last Update Date:2019-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO50803883Medicaid