Provider Demographics
NPI:1861542516
Name:GOOSE CREEK PHARMACY
Entity type:Organization
Organization Name:GOOSE CREEK PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST-OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GORDON
Authorized Official - Middle Name:
Authorized Official - Last Name:KOST
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:303-440-4200
Mailing Address - Street 1:7490 MOUNT MEEKER RD
Mailing Address - Street 2:
Mailing Address - City:LONGMONT
Mailing Address - State:CO
Mailing Address - Zip Code:80503-7143
Mailing Address - Country:US
Mailing Address - Phone:303-530-3531
Mailing Address - Fax:
Practice Address - Street 1:2880 FOLSOM ST
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80304-3739
Practice Address - Country:US
Practice Address - Phone:303-440-4200
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO11832183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO03357159Medicaid