Provider Demographics
NPI:1255856274
Name:WOOTEN, BRETT T
Entity Type:Individual
Prefix:DR
First Name:BRETT
Middle Name:T
Last Name:WOOTEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5751 SNOW CREEK PT APT 206
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80915-5053
Mailing Address - Country:US
Mailing Address - Phone:502-330-5327
Mailing Address - Fax:
Practice Address - Street 1:2890 N POWERS BLVD
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80922-2800
Practice Address - Country:US
Practice Address - Phone:719-573-4759
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-10
Last Update Date:2017-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0021875183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist