Provider Demographics
NPI:1083229868
Name:ROUGAS, TOM SAM (RPH)
Entity Type:Individual
Prefix:
First Name:TOM
Middle Name:SAM
Last Name:ROUGAS
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:93 PURDUE ST
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81005-1633
Mailing Address - Country:US
Mailing Address - Phone:719-671-7683
Mailing Address - Fax:
Practice Address - Street 1:25140 E US HIGHWAY 50
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81006-9737
Practice Address - Country:US
Practice Address - Phone:719-671-7683
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-09
Last Update Date:2020-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK14904183500000X
CO9153183500000X
CO9163183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist