Provider Demographics
NPI:1598101354
Name:MASON, JERRY (RPH)
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:
Last Name:MASON
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:PO BOX 773570
Mailing Address - Street 2:
Mailing Address - City:STEAMBOAT SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80477
Mailing Address - Country:US
Mailing Address - Phone:970-879-7317
Mailing Address - Fax:970-879-5895
Practice Address - Street 1:1825 CENTAL PARK DRIVE
Practice Address - Street 2:
Practice Address - City:STEAMBOAT SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80487
Practice Address - Country:US
Practice Address - Phone:970-879-7317
Practice Address - Fax:970-879-5895
Is Sole Proprietor?:No
Enumeration Date:2013-05-20
Last Update Date:2013-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO17885183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO48-0196590OtherTAX ID NUMBER