Provider Demographics
NPI:1013152198
Name:PROFESSIONAL PHARMACY LLC
Entity Type:Organization
Organization Name:PROFESSIONAL PHARMACY LLC
Other - Org Name:PROFESSIONAL PHARMACY, LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:KEN
Authorized Official - Middle Name:
Authorized Official - Last Name:WATERHOUSE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:719-532-9705
Mailing Address - Street 1:595 CHAPEL HILLS DR STE 104
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80920-1024
Mailing Address - Country:US
Mailing Address - Phone:719-633-8278
Mailing Address - Fax:719-228-6911
Practice Address - Street 1:595 CHAPEL HILLS DR STE 104
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80920-1024
Practice Address - Country:US
Practice Address - Phone:719-633-8278
Practice Address - Fax:719-228-6911
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-03
Last Update Date:2022-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO754333600000X
3336C0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO44283385Medicaid
2118132OtherPK