Basic Information
| Provider Information | |||||||||
| NPI: | 1255729380 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | POUDRE VALLEY HEALTH CARE INC. | ||||||||
| LastName: | |||||||||
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| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | POUDRE VALLEY HOSPITAL PHARMACY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 7901 E. LOWRY BLVD. | ||||||||
| Address2: | F402, 3RD FLOOR | ||||||||
| City: | DENVER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 80230 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7205531700 | ||||||||
| FaxNumber: | 7205531754 | ||||||||
| Practice Location | |||||||||
| Address1: | 1024 S LEMAY AVE | ||||||||
| Address2: | |||||||||
| City: | FORT COLLINS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 805243929 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9704957000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/23/2014 | ||||||||
| LastUpdateDate: | 01/07/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | RIEBER | ||||||||
| AuthorizedOfficialFirstName: | CHRISTOPHER | ||||||||
| AuthorizedOfficialMiddleName: | DANIEL | ||||||||
| AuthorizedOfficialTitleorPosition: | SR. VP & CFO | ||||||||
| AuthorizedOfficialTelephone: | 7208487836 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 01/07/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3336C0003X | 010305 | CO | N | Suppliers | Pharmacy | Community/Retail Pharmacy | 3336C0004X | 010305 | CO | N | Suppliers | Pharmacy | Compounding Pharmacy | 3336S0011X | 010305 | CO | N | Suppliers | Pharmacy | Specialty Pharmacy | 3336C0002X | 010305 | CO | N | Suppliers | Pharmacy | Clinic Pharmacy | 332B00000X | 010305 | CO | N | Suppliers | Durable Medical Equipment & Medical Supplies | 333600000X | 010305 | CO | Y | Suppliers | Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 0623238 | 01 | CO | NCPDP | OTHER | B001 | 01 | CO | TRICARE | OTHER | H188 | 01 | CO | MIDLAND'S CHOICE | OTHER | 1192523-00 | 05 | WY | MEDICAID | 0694280 | 01 | CO | AETNA | OTHER | 44054 | 01 | CO | GOV EMPLOYEE HOSPITAL ASSOCIATION | OTHER | 75276 | 01 | CO | WORLD INSURANCE | OTHER | 96934832 | 01 | CO | COLORADO INDIGENT | OTHER | 618515 | 01 | CO | STATE FARM | OTHER | 6160355 | 01 | CO | AMERICA'S HEALTH PLAN | OTHER | 00025PO | 01 | CO | BLUE CROSS COLORADO | OTHER | DE0901 | 01 | CO | RAILROAD MEDICARE | OTHER |