Provider Demographics
NPI:1518903087
Name:OMNICARE PHARMACY OF PUEBLO, LLC
Entity Type:Organization
Organization Name:OMNICARE PHARMACY OF PUEBLO, LLC
Other - Org Name:OMNICARE OF PUEBLO
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SR DIRECTOR, PAYER RELATIONS
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:COLBERT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:401-770-2751
Mailing Address - Street 1:1 CVS DR
Mailing Address - Street 2:BOX 1075
Mailing Address - City:WOONSOCKET
Mailing Address - State:RI
Mailing Address - Zip Code:02895-6146
Mailing Address - Country:US
Mailing Address - Phone:401-765-1500
Mailing Address - Fax:
Practice Address - Street 1:4602 N ELIZABETH ST
Practice Address - Street 2:SUITE 190
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81008-2072
Practice Address - Country:US
Practice Address - Phone:719-544-2146
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-21
Last Update Date:2024-02-29
Deactivation Date:2024-02-20
Deactivation Code:
Reactivation Date:2024-02-29
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO31123775Medicaid
CO31123775Medicaid