Provider Demographics
NPI:1972869725
Name:VAIL VALLEY PHARMACY
Entity Type:Organization
Organization Name:VAIL VALLEY PHARMACY
Other - Org Name:VAIL VALLEY PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/OPERATOR
Authorized Official - Prefix:
Authorized Official - First Name:COURTNEY
Authorized Official - Middle Name:
Authorized Official - Last Name:LAMBRECHT
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:970-569-4150
Mailing Address - Street 1:PO BOX 2868
Mailing Address - Street 2:
Mailing Address - City:EDWARDS
Mailing Address - State:CO
Mailing Address - Zip Code:81632-2868
Mailing Address - Country:US
Mailing Address - Phone:970-476-7308
Mailing Address - Fax:970-476-7306
Practice Address - Street 1:105 EDWARDS VILLAGE BLVD STE G-107
Practice Address - Street 2:
Practice Address - City:EDWARDS
Practice Address - State:CO
Practice Address - Zip Code:81632
Practice Address - Country:US
Practice Address - Phone:970-569-4150
Practice Address - Fax:970-569-4149
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-05
Last Update Date:2014-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0004X
CO8393336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2131349OtherPK
CO92209769Medicaid