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General NPI Number Information
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NPI Number | 1700498839
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Entity Type | Individual
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Provider Name | TERA SISSON PHARMD
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Gender | Female
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Dates
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Enumeration Date | 08/19/2020
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Last Update Date | 08/19/2020
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Provider Practice Location Address
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Address Line | 915 W NORTHERN AVE
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City | PUEBLO
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State | CO
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Zip | 81004-3123
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Country | US
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Telephone | 719-545-1811
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Fax |
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Provider Business Mailing Address
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Address Line | 752 E THISTLE DR
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City | PUEBLO WEST
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State | CO
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Zip | 81007-2117
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Country | US
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Telephone |
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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 | 22356
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License Number State | CO
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