Healthcare Provider Details

I. General information

NPI: 1467886176
Provider Name (Legal Business Name): GREGORY RIEN GOOSSENS PHARMACIST
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/29/2013
Last Update Date: 08/29/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

215 6 TH ST
HOTCHKISS CO
81419
US

IV. Provider business mailing address

PO BOX 425
HOTCHKISS CO
81419
US

V. Phone/Fax

Practice location:
  • Phone: 970-872-2623
  • Fax:
Mailing address:
  • Phone: 970-319-0556
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number11664
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: