Healthcare Provider Details

I. General information

NPI: 1619072972
Provider Name (Legal Business Name): BERTHOUD DRUG, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/13/2006
Last Update Date: 08/05/2024
Certification Date: 08/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1241 LAKE AVE
BERTHOUD CO
80513
US

IV. Provider business mailing address

1241 LAKE AVE
BERTHOUD CO
80513
US

V. Phone/Fax

Practice location:
  • Phone: 970-532-2034
  • Fax: 970-532-4799
Mailing address:
  • Phone: 970-532-2034
  • Fax: 970-532-4799

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number0080000001
License Number StateCO

VIII. Authorized Official

Name: DR. JOSHUA ELIJAH JONES
Title or Position: OWNER
Credential: PHARMD
Phone: 970-532-2034