Provider Demographics
NPI:1720525124
Name:SISTERS OF CHARITY OF LEAVENWORTH HEALTH SYSTEM INC
Entity Type:Organization
Organization Name:SISTERS OF CHARITY OF LEAVENWORTH HEALTH SYSTEM INC
Other - Org Name:INTERMOUNTAIN HEALTH GOOD SAMARITAN PHARMACY
Other - Org Type:Other Name
Authorized Official - Title/Position:PIC, AO
Authorized Official - Prefix:
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:
Authorized Official - Last Name:MADRID
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:303-689-6121
Mailing Address - Street 1:PO BOX 912960
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80291-2960
Mailing Address - Country:US
Mailing Address - Phone:303-689-6121
Mailing Address - Fax:
Practice Address - Street 1:200 EXEMPLA CIR STE P1-142
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:CO
Practice Address - Zip Code:80026-3370
Practice Address - Country:US
Practice Address - Phone:303-689-6121
Practice Address - Fax:303-689-6126
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-23
Last Update Date:2023-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336I0012X
COPDO.16800001623336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336I0012XSuppliersPharmacyInstitutional Pharmacy
No333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2176193OtherPK