MEDICARE: MRS. DESIRAE RODRIGUEZ PHRM D

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	PHA.0024523	CO

General Provider Information

NPI Number	:	1881477453
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. DESIRAE RODRIGUEZ PHRM D

Provider Business Mailing Address
First Line	:	1330 KELLY JOHNSON BLVD APT 312
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80920-4092
Country	:	US
Telephone Number	:	505-715-7424
Fax Number	:

Provider Business Practice Location Address
First Line	:	5060 N ACADEMY BLVD
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80918-4124
Country	:	US
Telephone Number	:	719-593-1343
Fax Number	:

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

Provider Enumeration Date	:	08/16/2023
Last Update Date	:	08/16/2023

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