Healthcare Provider Details

I. General information

NPI: 1649215864
Provider Name (Legal Business Name): 1200 MADISON SREET INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/19/2006
Last Update Date: 02/07/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 MADISON ST
DENVER CO
80206-3440
US

IV. Provider business mailing address

1200 MADISON ST
DENVER CO
80206-3440
US

V. Phone/Fax

Practice location:
  • Phone: 303-388-3679
  • Fax: 303-393-7604
Mailing address:
  • Phone: 303-388-3679
  • Fax: 303-393-7604

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberPDO30
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: JIT DHALIWAL
Title or Position: PRESIDENT
Credential:
Phone: 303-388-3679