Provider Demographics
NPI:1609100957
Name:KAISER PERMANENTE HEALTH PLAN OF COLORADO
Entity Type:Organization
Organization Name:KAISER PERMANENTE HEALTH PLAN OF COLORADO
Other - Org Name:KAISER PERMANENTE PUEBLO NORTH PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:REGIONAL ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:DENESE
Authorized Official - Middle Name:
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:303-326-6717
Mailing Address - Street 1:3670 PARKER BLVD
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81008-2285
Mailing Address - Country:US
Mailing Address - Phone:719-595-5367
Mailing Address - Fax:719-595-5370
Practice Address - Street 1:3670 PARKER BLVD
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81008-2285
Practice Address - Country:US
Practice Address - Phone:719-595-5367
Practice Address - Fax:719-595-5370
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-18
Last Update Date:2021-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO7793336M0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336M0003XSuppliersPharmacyManaged Care Organization Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2121958OtherPK