Provider Demographics
NPI:1467128579
Name:TEBBE, SPENCER BLAKE
Entity Type:Individual
Prefix:
First Name:SPENCER
Middle Name:BLAKE
Last Name:TEBBE
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 1:819 S DOWNING ST
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80209-4435
Mailing Address - Country:US
Mailing Address - Phone:317-966-1849
Mailing Address - Fax:
Practice Address - Street 1:360 S COLORADO BLVD
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CO
Practice Address - Zip Code:80246-1205
Practice Address - Country:US
Practice Address - Phone:720-258-8203
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-18
Last Update Date:2021-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0023667183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist