Healthcare Provider Details

I. General information

NPI: 1407907488
Provider Name (Legal Business Name): OPERA HOUSE PHARMACY CO INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/16/2007
Last Update Date: 10/12/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

223 COLORADO AVE
LA JUNTA CO
81050-1517
US

IV. Provider business mailing address

223 COLORADO AVE PO BOX 377
LA JUNTA CO
81050-1517
US

V. Phone/Fax

Practice location:
  • Phone: 719-384-2521
  • Fax: 719-384-2523
Mailing address:
  • Phone: 719-384-2521
  • Fax: 719-384-2523

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number720000007
License Number StateCO

VIII. Authorized Official

Name: EDWARD VASQUEZ
Title or Position: PRESIDENT
Credential: R.PH
Phone: 719-384-2521