MEDICARE: STACIE COLSON PHARMD

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	1835P0018X	Pharmacist Clinician (PhC)/ Clinical Pharmacy Specialist	45540	TX

General Provider Information

NPI Number	:	1730593468
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STACIE COLSON PHARMD

Provider Business Mailing Address
First Line	:	1125 COLLEGE AVE
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76104-4514
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1125 COLLEGE AVE
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76104-4514
Country	:	US
Telephone Number	:	817-336-1640
Fax Number	:

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

Provider Enumeration Date	:	06/20/2014
Last Update Date	:	06/20/2014

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Directions to “ STACIE COLSON PHARMD” Practice Location

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