Healthcare Provider Details

I. General information

NPI: 1548365992
Provider Name (Legal Business Name): SMITHBURG RETAIL ENTERPRISE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/13/2006
Last Update Date: 08/22/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 MAIN ST.
LIMON CO
80828
US

IV. Provider business mailing address

PO BOX 609
LIMON CO
80828-0609
US

V. Phone/Fax

Practice location:
  • Phone: 719-775-2371
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number780000001
License Number StateCO

VIII. Authorized Official

Name: RYAN SMITHBURG
Title or Position: OWNER
Credential:
Phone: 719-775-2371