Provider Demographics
NPI:1568483519
Name:BETHEL BUSINESS LLC
Entity Type:Organization
Organization Name:BETHEL BUSINESS LLC
Other - Org Name:IVYWILD PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LAWRENCE
Authorized Official - Middle Name:
Authorized Official - Last Name:BETHEL
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:719-547-7557
Mailing Address - Street 1:311 S NEVADA AVE
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80903-2107
Mailing Address - Country:US
Mailing Address - Phone:719-634-5541
Mailing Address - Fax:719-634-0692
Practice Address - Street 1:311 S NEVADA AVE
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80903-2107
Practice Address - Country:US
Practice Address - Phone:719-634-5541
Practice Address - Fax:719-634-0692
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-22
Last Update Date:2024-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X, 3336L0003X
COPDO02400000193336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO64108066Medicaid
CO03380508Medicaid
2140939OtherPK