Provider Demographics
NPI:1548540172
Name:MADER, JEREMIAH
Entity type:Individual
Prefix:MR
First Name:JEREMIAH
Middle Name:
Last Name:MADER
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 1:2306 N WAHSATCH AVE
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80907-6957
Mailing Address - Country:US
Mailing Address - Phone:719-516-1640
Mailing Address - Fax:
Practice Address - Street 1:2306 N WAHSATCH AVE
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80907-6957
Practice Address - Country:US
Practice Address - Phone:719-216-1640
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-26
Last Update Date:2016-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KSKS1-13891183500000X
CO16603183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist