MEDICARE: MARILLAC CLINIC, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	3336C0003X	Community/Retail Pharmacy

General Provider Information

NPI Number	:	1518704816
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MARILLAC CLINIC, INC.

Provider Business Mailing Address
First Line	:	2333 N 6TH ST
Second Line	:
City	:	GRAND JUNCTION
State	:	CO
Zip	:	81501-2001
Country	:	US
Telephone Number	:	970-200-1600
Fax Number	:	970-200-1600

Provider Business Practice Location Address
First Line	:	526 29 1/2 RD
Second Line	:
City	:	GRAND JUNCTION
State	:	CO
Zip	:	81504-5383
Country	:	US
Telephone Number	:	705-498-5779
Fax Number	:	970-549-8650

Authorized Official
Title or Position	:	CEO
Name	:	LATA RAMACHANDRAN
Credential	:
Telephone Number	:	970-200-1600

Provider Enumeration Date	:	07/12/2024
Last Update Date	:	02/13/2026

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Directions to “MARILLAC CLINIC, INC. ” Practice Location

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