Healthcare Provider Details

I. General information

NPI: 1487903811
Provider Name (Legal Business Name): PAUL SODERBERG RPH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/30/2012
Last Update Date: 08/30/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

POB 1302 101 MARTIN WAY
KREMMLING CO
80459-1302
US

IV. Provider business mailing address

PO BOX 1302 308 10TH ST N.
KREMMLING CO
80459-1302
US

V. Phone/Fax

Practice location:
  • Phone: 970-724-3205
  • Fax: 970-724-3225
Mailing address:
  • Phone: 970-724-3205
  • Fax: 970-724-3225

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number15393
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: