Provider Demographics
NPI:1982373817
Name:ALBERICO, RYAN MATTHEW
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:MATTHEW
Last Name:ALBERICO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1006 YAMPA AVE APT 17
Mailing Address - Street 2:
Mailing Address - City:CRAIG
Mailing Address - State:CO
Mailing Address - Zip Code:81625-2163
Mailing Address - Country:US
Mailing Address - Phone:650-773-4927
Mailing Address - Fax:
Practice Address - Street 1:750 HOSPITAL LOOP
Practice Address - Street 2:
Practice Address - City:CRAIG
Practice Address - State:CO
Practice Address - Zip Code:81625-8750
Practice Address - Country:US
Practice Address - Phone:970-826-3055
Practice Address - Fax:970-826-3058
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-13
Last Update Date:2021-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO291434183500000X
CO21995183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty