Healthcare Provider Details

I. General information

NPI: 1932453289
Provider Name (Legal Business Name): PAGOSA P&C INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/07/2012
Last Update Date: 12/08/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

426 PAGOSA STREET
PAGOSA SPRINGS CO
81147
US

IV. Provider business mailing address

P.O. BOX 120 426 PAGOSA STREET,
PAGOSA SPRINGS CO
81147
US

V. Phone/Fax

Practice location:
  • Phone: 970-264-4166
  • Fax: 970-264-3289
Mailing address:
  • Phone: 970-264-4166
  • Fax: 970-264-3289

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberPDO.1000000001
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License NumberPDO.1000000001
License Number StateCO
# 3
Primary TaxonomyN
Taxonomy Code3336S0011X
TaxonomySpecialty Pharmacy
License NumberPDO.1000000001
License Number StateCO

VIII. Authorized Official

Name: TOBY LIROT
Title or Position: VICE-PRESIDENT
Credential:
Phone: 970-264-4166