Healthcare Provider Details

I. General information

NPI: 1538238464
Provider Name (Legal Business Name): LIROT INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/07/2006
Last Update Date: 10/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

871 COUNTY ROAD 501
BAYFIELD CO
81122
US

IV. Provider business mailing address

PO BOX 110
BAYFIELD CO
81122-0110
US

V. Phone/Fax

Practice location:
  • Phone: 970-884-9133
  • Fax:
Mailing address:
  • Phone: 970-884-9133
  • Fax: 970-884-0723

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number1420000001
License Number StateCO

VIII. Authorized Official

Name: DR. WILLIAM JERROD CUSICK
Title or Position: PRESIDENT, PHARMACIST
Credential: PHARM D
Phone: 970-884-9133