Provider Demographics
NPI:1649215864
Name:1200 MADISON SREET INC
Entity Type:Organization
Organization Name:1200 MADISON SREET INC
Other - Org Name:CAPITOL HEIGHTS PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JIT
Authorized Official - Middle Name:
Authorized Official - Last Name:DHALIWAL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:303-388-3679
Mailing Address - Street 1:1200 MADISON ST
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80206-3440
Mailing Address - Country:US
Mailing Address - Phone:303-388-3679
Mailing Address - Fax:303-393-7604
Practice Address - Street 1:1200 MADISON ST
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80206-3440
Practice Address - Country:US
Practice Address - Phone:303-388-3679
Practice Address - Fax:303-393-7604
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-19
Last Update Date:2011-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPDO303336C0003X
3336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO62103571Medicaid
0601496OtherNCPDP PROVIDER IDENTIFICATION NUMBER