Provider Demographics
NPI:1295146512
Name:POUDRE VALLEY HEALTH CARE, INC
Entity type:Organization
Organization Name:POUDRE VALLEY HEALTH CARE, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:THOMPSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:970-495-7000
Mailing Address - Street 1:7901 E LOWRY BLVD
Mailing Address - Street 2:MAIL STOP F402
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80230-6507
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2121 E HARMONY RD UNIT 150
Practice Address - Street 2:
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80528-3413
Practice Address - Country:US
Practice Address - Phone:970-493-6337
Practice Address - Fax:970-297-6038
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:POUDRE VALLEY HEALTH CARE, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-05-09
Last Update Date:2024-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336C0004X, 333600000X, 3336C0002X, 3336C0003X
COPDO.00000008423336H0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336H0001XSuppliersPharmacyHome Infusion Therapy Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No333600000XSuppliersPharmacy
No3336C0002XSuppliersPharmacyClinic Pharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2145644OtherPK