Provider Demographics
NPI:1558986703
Name:HART, MONIQUE
Entity Type:Individual
Prefix:
First Name:MONIQUE
Middle Name:
Last Name:HART
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11148 FALLING SNOW LN
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80908-3757
Mailing Address - Country:US
Mailing Address - Phone:720-628-9297
Mailing Address - Fax:
Practice Address - Street 1:3480 N ACADEMY BLVD
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80917-5086
Practice Address - Country:US
Practice Address - Phone:719-380-9438
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-13
Last Update Date:2020-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03337824183500000X
COPHA.0023144183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist