Provider Demographics
NPI:1750022919
Name:SOEDARSONO, FERA (PHARMD)
Entity Type:Individual
Prefix:
First Name:FERA
Middle Name:
Last Name:SOEDARSONO
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15310 E COLFAX AVE
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:CO
Mailing Address - Zip Code:80011-5806
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:15310 E COLFAX AVE
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80011-5806
Practice Address - Country:US
Practice Address - Phone:720-262-4615
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-04
Last Update Date:2022-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0023917183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist