=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366889115
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GRACE HEALTH PHARMACY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/03/2013
-----------------------------------------------------
Last Update Date | 06/07/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3191 S VAUGHN WAY UNIT 102 UNIT 102
-----------------------------------------------------
City | AURORA
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80014-3505
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 720-748-2449
-----------------------------------------------------
Fax | 720-748-5324
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3191 S VAUGHN WAY # 102
-----------------------------------------------------
City | AURORA
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80014-3505
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 720-748-2449
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHARMACY MANAGER
-----------------------------------------------------
Name | PAUL KOERNER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 720-748-2449
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 333600000X
-----------------------------------------------------
Taxonomy Name | Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 3336C0004X
-----------------------------------------------------
Taxonomy Name | Compounding Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | 1680000031
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------