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General NPI Number Information
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NPI Number | 1407322613
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Entity Type | Individual
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Provider Name | WILLIAM J CUSICK
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Gender | Male
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Dates
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Enumeration Date | 10/16/2018
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Last Update Date | 10/16/2018
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Provider Practice Location Address
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Address Line | 871 COUNTY ROAD 501
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City | BAYFIELD
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State | CO
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Zip | 81122-9462
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Country | US
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Telephone | 970-884-9133
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Fax |
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Provider Business Mailing Address
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Address Line | 695 HARVARD AVE
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City | PAGOSA SPRINGS
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State | CO
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Zip | 81147-7244
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Country | US
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Telephone | 970-884-9133
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 183500000X
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Taxonomy Name | Pharmacist
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License Number | 0021158
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License Number State | CO
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