MEDICARE: SIDNEY LEROY DOMIER 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	10669	CO

General Provider Information

NPI Number	:	1710942362
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SIDNEY LEROY DOMIER RPH

Provider Business Mailing Address
First Line	:	145 CALLE DEL SOL
Second Line	:	PO BOX 656
City	:	FLORISSANT
State	:	CO
Zip	:	80816-9012
Country	:	US
Telephone Number	:	719-748-7389
Fax Number	:	719-575-9406

Provider Business Practice Location Address
First Line	:	209 S NEVADA AVE
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80903-1906
Country	:	US
Telephone Number	:	719-633-2762
Fax Number	:	719-575-9406

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

Provider Enumeration Date	:	04/18/2006
Last Update Date	:	07/08/2007

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