Healthcare Provider Details

I. General information

NPI: 1356169395
Provider Name (Legal Business Name): TAPAN BANTAWA PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/30/2024
Last Update Date: 09/30/2024
Certification Date: 09/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4745 ARAPAHOE AVE STE 140
BOULDER CO
80303-1082
US

IV. Provider business mailing address

12668 JASMINE ST
THORNTON CO
80602-4666
US

V. Phone/Fax

Practice location:
  • Phone: 720-214-0963
  • Fax:
Mailing address:
  • Phone: 303-717-3364
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number0024947
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: