Healthcare Provider Details

I. General information

NPI: 1770114407
Provider Name (Legal Business Name): FOUR CORNERS PHARMACY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/31/2020
Last Update Date: 06/23/2022
Certification Date: 06/23/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1185 S. CAMINO DEL RIO 160
DURANGO CO
81303-6888
US

IV. Provider business mailing address

1185 S. CAMINO DEL RIO 160
DURANGO CO
81303-6888
US

V. Phone/Fax

Practice location:
  • Phone: 970-247-1434
  • Fax: 970-247-7776
Mailing address:
  • Phone: 970-247-1434
  • Fax: 970-247-7776

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: SOPHIA D BOJORQUEZ
Title or Position: DIRECTOR
Credential:
Phone: 702-573-6861