Provider Demographics
NPI:1568744662
Name:LEWIS, JERRY BRET (RPH)
Entity Type:Individual
Prefix:MR
First Name:JERRY
Middle Name:BRET
Last Name:LEWIS
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 1:4315 CENTENNIAL BLVD
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80907-3769
Mailing Address - Country:US
Mailing Address - Phone:719-264-1400
Mailing Address - Fax:719-264-1097
Practice Address - Street 1:4315 CENTENNIAL BLVD
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80907-3769
Practice Address - Country:US
Practice Address - Phone:719-264-1400
Practice Address - Fax:719-264-1097
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-14
Last Update Date:2011-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO11669183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist