Healthcare Provider Details

I. General information

NPI: 1801818398
Provider Name (Legal Business Name): PUEBLO COMMUNITY HEALTH CENTER INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/24/2006
Last Update Date: 03/17/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 E ROUTT AVE
PUEBLO CO
81004-2117
US

IV. Provider business mailing address

110 E ROUTT AVE
PUEBLO CO
81004-2117
US

V. Phone/Fax

Practice location:
  • Phone: 719-543-8718
  • Fax: 719-543-6505
Mailing address:
  • Phone: 719-543-8718
  • Fax: 719-543-6505

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number1040000066
License Number StateCO

VIII. Authorized Official

Name: JUSTIN MCCARTHY
Title or Position: COO
Credential:
Phone: 719-543-8718