Basic Information
| Provider Information | |||||||||
| NPI: | 1710942362 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DOMIER | ||||||||
| FirstName: | SIDNEY | ||||||||
| MiddleName: | LEROY | ||||||||
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| Credential: | RPH | ||||||||
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| Mailing Information | |||||||||
| Address1: | 145 CALLE DEL SOL | ||||||||
| Address2: | PO BOX 656 | ||||||||
| City: | FLORISSANT | ||||||||
| State: | CO | ||||||||
| PostalCode: | 808169012 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7197487389 | ||||||||
| FaxNumber: | 7195759406 | ||||||||
| Practice Location | |||||||||
| Address1: | 209 S NEVADA AVE | ||||||||
| Address2: | |||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809031906 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7196332762 | ||||||||
| FaxNumber: | 7195759406 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/18/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183500000X | 10669 | CO | Y | Pharmacy Service Providers | Pharmacist |
No ID Information.