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General NPI Number Information
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NPI Number | 1578860805
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Entity Type | Organization
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Legal Business Name | BONNIE BRAE DRUGSTORE LLC
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Dates
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Enumeration Date | 02/23/2011
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Last Update Date | 02/15/2012
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Provider Practice Location Address
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Address Line | 2700 E LOUISIANA AVE APT 102
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City | DENVER
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State | CO
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Zip | 80210-2009
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Country | US
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Telephone | 303-722-7892
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Fax | 720-223-7269
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Provider Business Mailing Address
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Address Line | 2700 E LOUISIANA AVE APT 102
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City | DENVER
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State | CO
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Zip | 80210-2009
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Country | US
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Telephone | 303-722-7892
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Fax | 720-223-7269
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Authorized Official
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Title or Position | OWNER/MANAGER
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Name | BENJAMIN LAGER
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Credential |
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Telephone | 303-722-7892
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 333600000X
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Taxonomy Name | Pharmacy
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 3336C0003X
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Taxonomy Name | Community/Retail Pharmacy
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License Number | PDO-816
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License Number State | CO
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