Provider Demographics
NPI:1912909987
Name:POUDRE INFUSION THERAPY LLC
Entity Type:Organization
Organization Name:POUDRE INFUSION THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO/COO
Authorized Official - Prefix:
Authorized Official - First Name:BARRY
Authorized Official - Middle Name:KENT
Authorized Official - Last Name:FANCHER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:970-482-0198
Mailing Address - Street 1:915 CENTRE AVE
Mailing Address - Street 2:SUITE 3
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80526-6045
Mailing Address - Country:US
Mailing Address - Phone:970-494-2130
Mailing Address - Fax:970-494-2131
Practice Address - Street 1:915 CENTRE AVE
Practice Address - Street 2:SUITE 3
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80526-6045
Practice Address - Country:US
Practice Address - Phone:970-494-2130
Practice Address - Fax:970-494-2131
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-10
Last Update Date:2017-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO440000021332BP3500X, 3336H0001X, 3336S0011X
440000021332BP3500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BP3500XSuppliersDurable Medical Equipment & Medical SuppliesParenteral & Enteral Nutrition
No3336H0001XSuppliersPharmacyHome Infusion Therapy Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO90204247Medicaid
COCOB4272Medicare PIN
1912909987Medicare UPIN
CO3877850001Medicare NSC
3788750001Medicare NSC
COB4272Medicare PIN