Healthcare Provider Details

I. General information

NPI: 1437339611
Provider Name (Legal Business Name): MR. SEAN EDWARD ETIENNE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/06/2007
Last Update Date: 02/26/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3920 N UNION BLVD STE 200
COLORADO SPRINGS CO
80907-4921
US

IV. Provider business mailing address

3920 N UNION BLVD STE 200
COLORADO SPRINGS CO
80907-4921
US

V. Phone/Fax

Practice location:
  • Phone: 719-524-7616
  • Fax:
Mailing address:
  • Phone: 719-524-7616
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number12402-040
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number116685
License Number StateMN
# 3
Primary TaxonomyN
Taxonomy Code1835P2201X
TaxonomyAmbulatory Care Pharmacist
License NumberPHA0019012
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: