Provider Demographics
NPI:1831667518
Name:MEDINA, IRENE
Entity Type:Individual
Prefix:
First Name:IRENE
Middle Name:
Last Name:MEDINA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5708 APALOOSA DR
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80923-1115
Mailing Address - Country:US
Mailing Address - Phone:719-963-9987
Mailing Address - Fax:
Practice Address - Street 1:3960 MAIZELAND RD
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80909-1608
Practice Address - Country:US
Practice Address - Phone:719-444-4774
Practice Address - Fax:719-227-9917
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-11
Last Update Date:2018-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO13573183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty