Healthcare Provider Details

I. General information

NPI: 1982987269
Provider Name (Legal Business Name): MARK JURICH PHARMACIST
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/23/2011
Last Update Date: 09/23/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

725 W BAPTIST RD
COLORADO SPRINGS CO
80921-2454
US

IV. Provider business mailing address

725 W BAPTIST RD
COLORADO SPRINGS CO
80921-2454
US

V. Phone/Fax

Practice location:
  • Phone: 719-219-0230
  • Fax: 719-219-0236
Mailing address:
  • Phone: 719-219-0230
  • Fax: 719-219-0236

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number11773
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: