MEDICARE: JOHN D HUMPHREY

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	12089	CO

General Provider Information

NPI Number	:	1639423429
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOHN D HUMPHREY

Provider Business Mailing Address
First Line	:	6520 S ACADEMY BLVD
Second Line	:	SAFEWAY PHARMACY
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80906-8614
Country	:	US
Telephone Number	:	719-527-4807
Fax Number	:

Provider Business Practice Location Address
First Line	:	6520 S ACADEMY BLVD
Second Line	:	SAFEWAY PHARMACY
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80906-8614
Country	:	US
Telephone Number	:	719-527-4807
Fax Number	:

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

Provider Enumeration Date	:	11/01/2012
Last Update Date	:	11/01/2012

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