Provider Demographics
NPI:1871519918
Name:COLORADO STATE UNIVERSITY
Entity type:Organization
Organization Name:COLORADO STATE UNIVERSITY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACY MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MICHELE
Authorized Official - Middle Name:D
Authorized Official - Last Name:BROWN
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:970-491-1402
Mailing Address - Street 1:151 W LAKE ST SUITE 1100
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80523-8031
Mailing Address - Country:US
Mailing Address - Phone:970-491-1402
Mailing Address - Fax:970-491-4874
Practice Address - Street 1:151 W LAKE ST SUITE 1100
Practice Address - Street 2:COLORADO STATE UNIVERSITY
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80523-8031
Practice Address - Country:US
Practice Address - Phone:970-491-1402
Practice Address - Fax:970-491-4874
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-14
Last Update Date:2025-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
COPDO09900000103336C0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0002XSuppliersPharmacyClinic Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO25929763Medicaid
2001415OtherPK