Provider Demographics
NPI:1487275129
Name:SHAVANO PHARMACY LLC
Entity type:Organization
Organization Name:SHAVANO PHARMACY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:REBECCA
Authorized Official - Middle Name:ANNE
Authorized Official - Last Name:SEAMAN
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:719-398-6550
Mailing Address - Street 1:7290 W US HIGHWAY 50
Mailing Address - Street 2:
Mailing Address - City:SALIDA
Mailing Address - State:CO
Mailing Address - Zip Code:81201-9340
Mailing Address - Country:US
Mailing Address - Phone:719-398-6550
Mailing Address - Fax:719-398-6560
Practice Address - Street 1:415 US HIGHWAY 24 N
Practice Address - Street 2:
Practice Address - City:BUENA VISTA
Practice Address - State:CO
Practice Address - Zip Code:81211
Practice Address - Country:US
Practice Address - Phone:816-804-6412
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-05-05
Last Update Date:2020-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO1053755363Medicaid