Provider Demographics
NPI:1710049390
Name:FOOTHILLS FAMILY PHARMACY OF LAFAYETTE, LLC
Entity Type:Organization
Organization Name:FOOTHILLS FAMILY PHARMACY OF LAFAYETTE, LLC
Other - Org Name:FOOTHILLS FAMILY PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CALVIN
Authorized Official - Middle Name:THOMAS
Authorized Official - Last Name:TYREE
Authorized Official - Suffix:JR
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:303-604-5010
Mailing Address - Street 1:1000 W SOUTH BOULDER RD
Mailing Address - Street 2:SUITE 107
Mailing Address - City:LAFAYETTE
Mailing Address - State:CO
Mailing Address - Zip Code:80026-2752
Mailing Address - Country:US
Mailing Address - Phone:303-604-5010
Mailing Address - Fax:303-604-5015
Practice Address - Street 1:1000 W SOUTH BOULDER RD
Practice Address - Street 2:SUITE 107
Practice Address - City:LAFAYETTE
Practice Address - State:CO
Practice Address - Zip Code:80026-2752
Practice Address - Country:US
Practice Address - Phone:303-604-5010
Practice Address - Fax:303-604-5015
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO5673336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
0619138OtherNCPDP