Provider Demographics
NPI:1679552475
Name:VAIL CLINIC INC
Entity type:Organization
Organization Name:VAIL CLINIC INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACY MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:ARNETT
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:970-479-7253
Mailing Address - Street 1:PO BOX 40000
Mailing Address - Street 2:C/O VAIL PHARMACY
Mailing Address - City:VAIL
Mailing Address - State:CO
Mailing Address - Zip Code:81658-7520
Mailing Address - Country:US
Mailing Address - Phone:970-479-7253
Mailing Address - Fax:970-479-7180
Practice Address - Street 1:181 W. MEADOW DRIVE
Practice Address - Street 2:
Practice Address - City:VAIL
Practice Address - State:CO
Practice Address - Zip Code:81657
Practice Address - Country:US
Practice Address - Phone:970-479-7253
Practice Address - Fax:970-479-7180
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-11
Last Update Date:2018-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO12200000053336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3336C0003XSuppliersPharmacyCommunity/Retail PharmacyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO03002177Medicaid
CO03002177Medicaid