Healthcare Provider Details

I. General information

NPI: 1013152198
Provider Name (Legal Business Name): PROFESSIONAL PHARMACY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/03/2008
Last Update Date: 02/24/2022
Certification Date: 02/24/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

595 CHAPEL HILLS DR STE 104
COLORADO SPRINGS CO
80920-1024
US

IV. Provider business mailing address

595 CHAPEL HILLS DR STE 104
COLORADO SPRINGS CO
80920-1024
US

V. Phone/Fax

Practice location:
  • Phone: 719-633-8278
  • Fax: 719-228-6911
Mailing address:
  • Phone: 719-633-8278
  • Fax: 719-228-6911

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number754
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: KEN WATERHOUSE
Title or Position: CFO
Credential:
Phone: 719-532-9705