Provider Demographics
NPI:1801304068
Name:RERICK, VICTORIA KENE (PHARMD)
Entity type:Individual
Prefix:
First Name:VICTORIA
Middle Name:KENE
Last Name:RERICK
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:TORI
Other - Middle Name:
Other - Last Name:RERICK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:603 KEN PRATT BLVD
Mailing Address - Street 2:
Mailing Address - City:LONGMONT
Mailing Address - State:CO
Mailing Address - Zip Code:80501-6419
Mailing Address - Country:US
Mailing Address - Phone:303-827-3480
Mailing Address - Fax:303-827-3540
Practice Address - Street 1:603 KEN PRATT BLVD
Practice Address - Street 2:
Practice Address - City:LONGMONT
Practice Address - State:CO
Practice Address - Zip Code:80501-6419
Practice Address - Country:US
Practice Address - Phone:303-827-3480
Practice Address - Fax:303-827-3540
Is Sole Proprietor?:No
Enumeration Date:2018-01-22
Last Update Date:2018-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPHA-21333183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist