Provider Demographics
NPI:1992148621
Name:PAVLICK, PETER (RPH)
Entity type:Individual
Prefix:
First Name:PETER
Middle Name:
Last Name:PAVLICK
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 1:815 CHEYENNE MEADOWS RD
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80906-4929
Mailing Address - Country:US
Mailing Address - Phone:719-527-1640
Mailing Address - Fax:719-538-6056
Practice Address - Street 1:815 CHEYENNE MEADOWS RD
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80906-4929
Practice Address - Country:US
Practice Address - Phone:719-527-1640
Practice Address - Fax:719-538-6056
Is Sole Proprietor?:No
Enumeration Date:2013-04-11
Last Update Date:2013-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO10492183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist