Provider Demographics
NPI:1205832789
Name:CENTRE PHARMACY INC
Entity type:Organization
Organization Name:CENTRE PHARMACY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHRM MANG
Authorized Official - Prefix:
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:
Authorized Official - Last Name:ELLIS
Authorized Official - Suffix:
Authorized Official - Credentials:PHRM
Authorized Official - Phone:970-221-0190
Mailing Address - Street 1:915 CENTRE AVE
Mailing Address - Street 2:SUITE 4
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80526-6045
Mailing Address - Country:US
Mailing Address - Phone:970-221-0190
Mailing Address - Fax:970-493-7680
Practice Address - Street 1:915 CENTRE AVE
Practice Address - Street 2:SUITE 4
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80526-6045
Practice Address - Country:US
Practice Address - Phone:970-221-0190
Practice Address - Fax:970-493-7680
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-21
Last Update Date:2017-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
CO4400000023336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2002676OtherPK
CO03002250Medicaid