Provider Demographics
NPI:1972694990
Name:PRESCRIPTION SHOP LLC
Entity type:Organization
Organization Name:PRESCRIPTION SHOP LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:T
Authorized Official - Last Name:SAJBEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:719-564-2200
Mailing Address - Street 1:1728 S PRAIRIE AVE
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81005
Mailing Address - Country:US
Mailing Address - Phone:719-564-0220
Mailing Address - Fax:719-564-0424
Practice Address - Street 1:1728 S PRAIRIE AVE
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81005
Practice Address - Country:US
Practice Address - Phone:719-564-0220
Practice Address - Fax:719-564-0424
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PESCRIPTION SHOP LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-09-27
Last Update Date:2024-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO10434333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
0605735OtherNCPDP
CO03665502Medicaid
CO03665502Medicaid