Provider Demographics
NPI:1689857153
Name:COLORADO COALITION FOR THE HOMELESS
Entity Type:Organization
Organization Name:COLORADO COALITION FOR THE HOMELESS
Other - Org Name:STOUT STREET CLINIC - PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:PETE
Authorized Official - Middle Name:J
Authorized Official - Last Name:STOLLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:303-312-9606
Mailing Address - Street 1:2130 STOUT STREET
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80205-2827
Mailing Address - Country:US
Mailing Address - Phone:303-293-3979
Mailing Address - Fax:303-293-6514
Practice Address - Street 1:2130 STOUT STREET
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80205-2827
Practice Address - Country:US
Practice Address - Phone:303-293-3979
Practice Address - Fax:303-293-6514
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-07
Last Update Date:2021-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0002XSuppliersPharmacyClinic Pharmacy
No261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO79000053Medicaid