Provider Demographics
NPI:1912985136
Name:PIONEER PHARMACY LLC
Entity Type:Organization
Organization Name:PIONEER PHARMACY LLC
Other - Org Name:PIONEER PHARMACY LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRANDON
Authorized Official - Middle Name:
Authorized Official - Last Name:HAGEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:303-525-7990
Mailing Address - Street 1:PO BOX 329
Mailing Address - Street 2:
Mailing Address - City:RIVERTON
Mailing Address - State:UT
Mailing Address - Zip Code:84065-0329
Mailing Address - Country:US
Mailing Address - Phone:303-252-2990
Mailing Address - Fax:303-252-7991
Practice Address - Street 1:3895 UPHAM ST
Practice Address - Street 2:STE 60
Practice Address - City:WHEAT RIDGE
Practice Address - State:CO
Practice Address - Zip Code:80033-4651
Practice Address - Country:US
Practice Address - Phone:303-252-7990
Practice Address - Fax:303-252-7991
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-06
Last Update Date:2016-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO6433336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2003854OtherPK
COA5857059Medicaid