MEDICARE: MR. TERRY LEE MATTHEWS RPH

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	10961	CO

General Provider Information

NPI Number	:	1164723979
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. TERRY LEE MATTHEWS RPH

Provider Business Mailing Address
First Line	:	1920 S NEVADA AVE
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80905-3407
Country	:	US
Telephone Number	:	719-636-5257
Fax Number	:	719-448-9818

Provider Business Practice Location Address
First Line	:	1920 S NEVADA AVE
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80905-3407
Country	:	US
Telephone Number	:	719-636-5257
Fax Number	:	719-448-9818

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/10/2010
Last Update Date	:	11/10/2010

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