Provider Demographics
NPI:1487903811
Name:SODERBERG, PAUL (RPH)
Entity type:Individual
Prefix:MR
First Name:PAUL
Middle Name:
Last Name:SODERBERG
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1302
Mailing Address - Street 2:308 10TH ST N.
Mailing Address - City:KREMMLING
Mailing Address - State:CO
Mailing Address - Zip Code:80459-1302
Mailing Address - Country:US
Mailing Address - Phone:970-724-3205
Mailing Address - Fax:970-724-3225
Practice Address - Street 1:POB 1302
Practice Address - Street 2:101 MARTIN WAY
Practice Address - City:KREMMLING
Practice Address - State:CO
Practice Address - Zip Code:80459-1302
Practice Address - Country:US
Practice Address - Phone:970-724-3205
Practice Address - Fax:970-724-3225
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-30
Last Update Date:2012-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO15393183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO15393OtherSTATE BOARD OF PHARMACY-PHARMACIST LICENSE