Provider Demographics
NPI:1710097969
Name:MESA PHARMACY OF PUEBLO, INC.
Entity Type:Organization
Organization Name:MESA PHARMACY OF PUEBLO, INC.
Other - Org Name:MESA PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACY MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MARGARET
Authorized Official - Middle Name:A
Authorized Official - Last Name:FRANTZ
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:719-544-1371
Mailing Address - Street 1:25140 E US HIGHWAY 50
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81006-9737
Mailing Address - Country:US
Mailing Address - Phone:719-544-1371
Mailing Address - Fax:719-546-1961
Practice Address - Street 1:25140 E US HIGHWAY 50
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81006-9737
Practice Address - Country:US
Practice Address - Phone:719-544-1371
Practice Address - Fax:719-546-1961
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-30
Last Update Date:2007-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO10429183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO03589223Medicaid
CO5940970001Medicare NSC