Healthcare Provider Details

I. General information

NPI: 1861911901
Provider Name (Legal Business Name): KACEY MARIE FAGLER PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/10/2017
Last Update Date: 11/08/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4800 BASELINE RD STE E107
BOULDER CO
80303-2643
US

IV. Provider business mailing address

120 EDGEVIEW DR APT 6407
BROOMFIELD CO
80021-8100
US

V. Phone/Fax

Practice location:
  • Phone: 303-499-1919
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberPH.36904
License Number StateSC
# 2
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number21555
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: