Healthcare Provider Details

I. General information

NPI: 1871130328
Provider Name (Legal Business Name): FRIEDA MARTHA MARTIN PHARMACIST
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: FRIEDA MARTHA HABIBI

II. Dates (important events)

Enumeration Date: 12/03/2019
Last Update Date: 12/03/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

555 E COSTILLA ST
COLORADO SPRINGS CO
80903-3764
US

IV. Provider business mailing address

555 E COSTILLA ST
COLORADO SPRINGS CO
80903-3764
US

V. Phone/Fax

Practice location:
  • Phone: 719-596-4449
  • Fax: 719-574-6686
Mailing address:
  • Phone: 719-596-4449
  • Fax: 719-574-6686

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License Number14485
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: