Provider Demographics
NPI:1831418581
Name:PDC PHARMACY COLORADO INC
Entity type:Organization
Organization Name:PDC PHARMACY COLORADO INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VP OF OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTINA
Authorized Official - Middle Name:
Authorized Official - Last Name:FUNKHOUSER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:412-820-1010
Mailing Address - Street 1:4665 NAUTILUS CT S
Mailing Address - Street 2:SUITE 101
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80301-3262
Mailing Address - Country:US
Mailing Address - Phone:303-530-1188
Mailing Address - Fax:303-530-1151
Practice Address - Street 1:4665 NAUTILUS CT S STE 101
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80301-3263
Practice Address - Country:US
Practice Address - Phone:303-530-1188
Practice Address - Fax:303-530-1151
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-20
Last Update Date:2018-12-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
COPDO-00000007993336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO31522548Medicaid
2125117OtherPK