Provider Demographics
NPI:1972871333
Name:HAVANA PHARMACY AND MEDICAL SUPPLY LLC
Entity type:Organization
Organization Name:HAVANA PHARMACY AND MEDICAL SUPPLY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:
Authorized Official - Last Name:SACKEY
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:303-668-0032
Mailing Address - Street 1:1555 S HAVANA ST UNIT HJ
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:CO
Mailing Address - Zip Code:80012-5004
Mailing Address - Country:US
Mailing Address - Phone:303-750-3600
Mailing Address - Fax:303-750-3607
Practice Address - Street 1:1555 S HAVANA ST UNIT HJ
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80012-5004
Practice Address - Country:US
Practice Address - Phone:303-750-3600
Practice Address - Fax:303-750-3607
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-13
Last Update Date:2014-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO8363336C0003X
3336C0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
0622363OtherNCPDP PROVIDER IDENTIFICATION NUMBER
CO6760150001Medicare NSC