Provider Demographics
NPI:1578860805
Name:BONNIE BRAE DRUGSTORE LLC
Entity Type:Organization
Organization Name:BONNIE BRAE DRUGSTORE LLC
Other - Org Name:BONNIE BRAE DRUGSTORE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:BENJAMIN
Authorized Official - Middle Name:
Authorized Official - Last Name:LAGER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:303-722-7892
Mailing Address - Street 1:2700 E LOUISIANA AVE APT 102
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80210-2009
Mailing Address - Country:US
Mailing Address - Phone:303-722-7892
Mailing Address - Fax:720-223-7269
Practice Address - Street 1:2700 E LOUISIANA AVE APT 102
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80210-2009
Practice Address - Country:US
Practice Address - Phone:303-722-7892
Practice Address - Fax:720-223-7269
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-23
Last Update Date:2012-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
COPDO-8163336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO54301378Medicaid
0622022OtherNCPDP PROVIDER IDENTIFICATION NUMBER