Provider Demographics
NPI:1942433198
Name:BATTLEMENT GROCERY LLC
Entity Type:Organization
Organization Name:BATTLEMENT GROCERY LLC
Other - Org Name:CLARKS PHARMACY BATTLEMENT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACY MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:RASMUSSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:970-285-5661
Mailing Address - Street 1:818 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BLANDING
Mailing Address - State:UT
Mailing Address - Zip Code:84511-3911
Mailing Address - Country:US
Mailing Address - Phone:970-925-5295
Mailing Address - Fax:970-925-5296
Practice Address - Street 1:71 SIPPRELLE DR
Practice Address - Street 2:
Practice Address - City:PARACHUTE
Practice Address - State:CO
Practice Address - Zip Code:81635-9232
Practice Address - Country:US
Practice Address - Phone:970-285-5661
Practice Address - Fax:970-285-0149
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-03
Last Update Date:2013-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPDO0000000781333600000X
3336C0002X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336C0002XSuppliersPharmacyClinic Pharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO1043536014Medicaid
2123278OtherPK
CO00021385Medicaid