Healthcare Provider Details

I. General information

NPI: 1386950269
Provider Name (Legal Business Name): SPENCER DANE HASLAM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/30/2010
Last Update Date: 12/08/2025
Certification Date: 12/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1650 COCHRANE CIR BLDG 7500
FORT CARSON CO
80913-4613
US

IV. Provider business mailing address

1650 COCHRANE CIR BLDG 7500
FORT CARSON CO
80913-4613
US

V. Phone/Fax

Practice location:
  • Phone: 719-526-7339
  • Fax:
Mailing address:
  • Phone: 719-526-7339
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberPS50890
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: