Provider Demographics
NPI:1699205971
Name:BLUE HAVEN VENTURES, LLC
Entity Type:Organization
Organization Name:BLUE HAVEN VENTURES, LLC
Other - Org Name:BLUE HAVEN PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGING MEMBER/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ROBERTO
Authorized Official - Middle Name:ROLANDO
Authorized Official - Last Name:OLIVARES
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMACIST
Authorized Official - Phone:512-693-4222
Mailing Address - Street 1:5625 EIGER RD STE 150
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78735-8980
Mailing Address - Country:US
Mailing Address - Phone:512-693-4222
Mailing Address - Fax:512-487-5311
Practice Address - Street 1:5625 EIGER RD STE 150
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78735-8980
Practice Address - Country:US
Practice Address - Phone:512-693-4222
Practice Address - Fax:512-487-5311
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-06-19
Last Update Date:2017-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX314593336C0003X
3336C0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy