Provider Demographics
NPI:1780026690
Name:SPRAGUE, COLIN DAVIS
Entity Type:Individual
Prefix:MR
First Name:COLIN
Middle Name:DAVIS
Last Name:SPRAGUE
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 1:3700 SOUTHERN BLVD STE 105
Mailing Address - Street 2:
Mailing Address - City:KETTERING
Mailing Address - State:OH
Mailing Address - Zip Code:45429-1265
Mailing Address - Country:US
Mailing Address - Phone:937-281-3883
Mailing Address - Fax:
Practice Address - Street 1:3700 SOUTHERN BLVD STE 105
Practice Address - Street 2:
Practice Address - City:KETTERING
Practice Address - State:OH
Practice Address - Zip Code:45429-1265
Practice Address - Country:US
Practice Address - Phone:937-281-3883
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-19
Last Update Date:2022-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03236519183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist