Provider Demographics
NPI:1780055434
Name:PHARMBLUE LLC
Entity type:Organization
Organization Name:PHARMBLUE LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:CARL
Authorized Official - Middle Name:CODY
Authorized Official - Last Name:COLQUITT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:469-592-2011
Mailing Address - Street 1:10604 COURSEY BLVD
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70816-4015
Mailing Address - Country:US
Mailing Address - Phone:469-592-2011
Mailing Address - Fax:
Practice Address - Street 1:5700 GRANITE PKWY STE 425
Practice Address - Street 2:
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75024-6648
Practice Address - Country:US
Practice Address - Phone:469-592-2011
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-07
Last Update Date:2024-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPP482599333600000X
3336L0003X, 3336S0011X, 3336C0004X
NY0352893336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1028110910002Medicaid
2154646OtherPK