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General NPI Number Information
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NPI Number | 1518704816
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Entity Type | Organization
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Legal Business Name | MARILLAC CLINIC, INC.
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Dates
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Enumeration Date | 07/12/2024
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Last Update Date | 02/13/2026
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Provider Practice Location Address
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Address Line | 526 29 1/2 RD
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City | GRAND JUNCTION
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State | CO
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Zip | 81504-5383
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Country | US
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Telephone | 705-498-5779
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Fax | 970-549-8650
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Provider Business Mailing Address
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Address Line | 2333 N 6TH ST
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City | GRAND JUNCTION
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State | CO
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Zip | 81501-2001
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Country | US
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Telephone | 970-200-1600
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Fax | 970-200-1600
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Authorized Official
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Title or Position | CEO
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Name | LATA RAMACHANDRAN
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Credential |
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Telephone | 970-200-1600
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 3336C0003X
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Taxonomy Name | Community/Retail Pharmacy
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License Number |
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License Number State |
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