Healthcare Provider Details

I. General information

NPI: 1194897447
Provider Name (Legal Business Name): CEDAREDGE PHARMACY INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/14/2006
Last Update Date: 02/14/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

215 W. MAIN ST
CEDAREDGE CO
81413
US

IV. Provider business mailing address

PO BOX 1044
CEDAREDGE CO
81413-1044
US

V. Phone/Fax

Practice location:
  • Phone: 970-856-3161
  • Fax: 970-856-3021
Mailing address:
  • Phone: 970-856-3161
  • Fax: 970-856-3021

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number20-1
License Number StateCO
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberPDOI200000001
License Number StateCO

VIII. Authorized Official

Name: MR. JOHN GEORGE BREITNAUER JR.
Title or Position: OWNER/PHARMACIST
Credential: RPH
Phone: 970-856-3161