Provider Demographics
NPI:1932453289
Name:PAGOSA P&C INC.
Entity Type:Organization
Organization Name:PAGOSA P&C INC.
Other - Org Name:PAGOSA SPECIALTY PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE-PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:TOBY
Authorized Official - Middle Name:
Authorized Official - Last Name:LIROT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:970-264-4166
Mailing Address - Street 1:P.O. BOX 120
Mailing Address - Street 2:426 PAGOSA STREET,
Mailing Address - City:PAGOSA SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:81147
Mailing Address - Country:US
Mailing Address - Phone:970-264-4166
Mailing Address - Fax:970-264-3289
Practice Address - Street 1:426 PAGOSA STREET
Practice Address - Street 2:
Practice Address - City:PAGOSA SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:81147
Practice Address - Country:US
Practice Address - Phone:970-264-4166
Practice Address - Fax:970-264-3289
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-07
Last Update Date:2015-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPDO.10000000013336C0003X, 3336C0004X, 3336S0011X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
COPDO.1000000001OtherBOARD OF PHARMACY
0622779OtherNCPDP PROVIDER IDENTIFICATION NUMBER