Provider Demographics
NPI:1770114407
Name:FOUR CORNERS PHARMACY, LLC
Entity type:Organization
Organization Name:FOUR CORNERS PHARMACY, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:SOPHIA
Authorized Official - Middle Name:D
Authorized Official - Last Name:BOJORQUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:702-573-6861
Mailing Address - Street 1:1185 S. CAMINO DEL RIO
Mailing Address - Street 2:160
Mailing Address - City:DURANGO
Mailing Address - State:CO
Mailing Address - Zip Code:81303-6888
Mailing Address - Country:US
Mailing Address - Phone:970-247-1434
Mailing Address - Fax:970-247-7776
Practice Address - Street 1:1185 S. CAMINO DEL RIO
Practice Address - Street 2:160
Practice Address - City:DURANGO
Practice Address - State:CO
Practice Address - Zip Code:81303-6888
Practice Address - Country:US
Practice Address - Phone:970-247-1434
Practice Address - Fax:970-247-7776
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-01-31
Last Update Date:2022-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy