Provider Demographics
NPI:1912240540
Name:PEAK VISTA COMMUNITY HEALTH CENTERS
Entity Type:Organization
Organization Name:PEAK VISTA COMMUNITY HEALTH CENTERS
Other - Org Name:PEAK VISTA PHARMACY AT ACADEMY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT & CEO
Authorized Official - Prefix:
Authorized Official - First Name:PAMELA
Authorized Official - Middle Name:
Authorized Official - Last Name:MCMANUS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:791-344-6453
Mailing Address - Street 1:3205 N ACADEMY BLVD
Mailing Address - Street 2:SUITE 130
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80917
Mailing Address - Country:US
Mailing Address - Phone:719-344-6914
Mailing Address - Fax:719-344-7865
Practice Address - Street 1:3207 N ACADEMY BLVD
Practice Address - Street 2:SUITE 1200
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80917
Practice Address - Country:US
Practice Address - Phone:719-632-5700
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PEAK VISTA COMMUNITY HEALTH CENTERS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-04-02
Last Update Date:2017-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPDO.1680000025333600000X
CO333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO9000143434Medicaid
CO05638267Medicaid
CO05638267Medicaid