Provider Demographics
NPI:1942437975
Name:BOCKRATH, EUGENE T
Entity Type:Individual
Prefix:
First Name:EUGENE
Middle Name:T
Last Name:BOCKRATH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2431 N UNION BLVD
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80909-1107
Mailing Address - Country:US
Mailing Address - Phone:719-630-3154
Mailing Address - Fax:
Practice Address - Street 1:2431 N UNION BLVD
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80909-1107
Practice Address - Country:US
Practice Address - Phone:719-630-3154
Practice Address - Fax:719-630-1640
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-17
Last Update Date:2016-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO03577319Medicaid
CO03577319Medicaid