Provider Demographics
NPI:1538764188
Name:BROWN, KEVIN MATTHEW
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:MATTHEW
Last Name:BROWN
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 1:3810 BLOOMINGTON ST
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80922-3203
Mailing Address - Country:US
Mailing Address - Phone:719-574-7493
Mailing Address - Fax:
Practice Address - Street 1:3810 BLOOMINGTON ST
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80922-3203
Practice Address - Country:US
Practice Address - Phone:719-574-7493
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-02
Last Update Date:2020-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0022638183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist