Provider Demographics
NPI:1659671154
Name:DEBOLT, MARK
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:DEBOLT
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 1:1414 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CANON CITY
Mailing Address - State:CO
Mailing Address - Zip Code:81212-3906
Mailing Address - Country:US
Mailing Address - Phone:719-275-7511
Mailing Address - Fax:719-275-7161
Practice Address - Street 1:1414 MAIN ST
Practice Address - Street 2:
Practice Address - City:CANON CITY
Practice Address - State:CO
Practice Address - Zip Code:81212-3906
Practice Address - Country:US
Practice Address - Phone:719-275-7511
Practice Address - Fax:719-275-7161
Is Sole Proprietor?:No
Enumeration Date:2010-10-30
Last Update Date:2010-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO16607183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist