Healthcare Provider Details

I. General information

NPI: 1235150285
Provider Name (Legal Business Name): PHARMACA INTEGRATIVE PHARMACY, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/22/2006
Last Update Date: 08/03/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1647 PEARL STREET
BOULDER CO
80302
US

IV. Provider business mailing address

4940 PEARL EAST CIRCLE SUITE 301
BOULDER CO
80301-2489
US

V. Phone/Fax

Practice location:
  • Phone: 303-442-5164
  • Fax: 303-939-9388
Mailing address:
  • Phone: 303-867-3182
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number90000004
License Number StateCO

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier0601787
Identifier TypeOTHER
Identifier State
Identifier IssuerOTHER ID NUMBER
# 2
Identifier58322272
Identifier TypeMEDICAID
Identifier StateCO
Identifier Issuer
# 3
Identifier58-322272
Identifier TypeMEDICAID
Identifier StateCO
Identifier Issuer
# 4
Identifier0601787
Identifier TypeOTHER
Identifier State
Identifier IssuerOTHER ID NUMBER-COMMERCIAL NUMBER

VIII. Authorized Official

Name: GREG LEGORE
Title or Position: DIRECTOR OF PHARMACY OPERATIONS
Credential:
Phone: 805-217-9926