Healthcare Provider Details

I. General information

NPI: 1346336997
Provider Name (Legal Business Name): LA JARA PHARMACEUTICAL CENTER, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/04/2006
Last Update Date: 04/17/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

412 MAIN STREET
LA JARA CO
81140
US

IV. Provider business mailing address

412 MAIN ST PO BOX 609
LA JARA CO
81140
US

V. Phone/Fax

Practice location:
  • Phone: 719-274-5109
  • Fax: 719-274-4246
Mailing address:
  • Phone: 719-274-5109
  • Fax: 719-274-4246

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License NumberAL7908114
License Number StateCO
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberAL7908114
License Number StateCO

VIII. Authorized Official

Name: MR. JOSEPH THOMAS VALDEZ
Title or Position: PHARMACIST OWNER
Credential: RPH
Phone: 719-274-5109