Provider Demographics
NPI:1801582341
Name:PURGATORY PHARMACEUTICAL SERVICES LLC
Entity type:Organization
Organization Name:PURGATORY PHARMACEUTICAL SERVICES LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER, PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:IAN
Authorized Official - Middle Name:
Authorized Official - Last Name:MCMULLEN
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:719-852-9894
Mailing Address - Street 1:PO BOX 546
Mailing Address - Street 2:
Mailing Address - City:CRESTONE
Mailing Address - State:CO
Mailing Address - Zip Code:81131-0546
Mailing Address - Country:US
Mailing Address - Phone:719-852-9894
Mailing Address - Fax:719-852-9897
Practice Address - Street 1:222 SOLAR AVE
Practice Address - Street 2:
Practice Address - City:MONTE VISTA
Practice Address - State:CO
Practice Address - Zip Code:81144-1066
Practice Address - Country:US
Practice Address - Phone:719-852-9894
Practice Address - Fax:719-852-9897
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-04-17
Last Update Date:2023-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy