Provider Demographics
NPI:1710942362
Name:DOMIER, SIDNEY LEROY (RPH)
Entity Type:Individual
Prefix:
First Name:SIDNEY
Middle Name:LEROY
Last Name:DOMIER
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 1:145 CALLE DEL SOL
Mailing Address - Street 2:PO BOX 656
Mailing Address - City:FLORISSANT
Mailing Address - State:CO
Mailing Address - Zip Code:80816-9012
Mailing Address - Country:US
Mailing Address - Phone:719-748-7389
Mailing Address - Fax:719-575-9406
Practice Address - Street 1:209 S NEVADA AVE
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80903-1906
Practice Address - Country:US
Practice Address - Phone:719-633-2762
Practice Address - Fax:719-575-9406
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO10669183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist