Basic Information
| Provider Information | |||||||||
| NPI: | 1306230883 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BLY | ||||||||
| FirstName: | MATT | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1258 | ||||||||
| Address2: | |||||||||
| City: | BRECKENRIDGE | ||||||||
| State: | CO | ||||||||
| PostalCode: | 804241258 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9703761666 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1055 CLERMONT ST | ||||||||
| Address2: | |||||||||
| City: | DENVER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802203808 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3033998020 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/24/2015 | ||||||||
| LastUpdateDate: | 03/24/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183500000X | 15584 | CO | Y | Pharmacy Service Providers | Pharmacist |
No ID Information.