Provider Demographics
NPI:1003349093
Name:BREITNAUER, JOHN GEORGE JR (RPH)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:GEORGE
Last Name:BREITNAUER
Suffix:JR
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:PO BOX 1044
Mailing Address - Street 2:215 W MAIN ST
Mailing Address - City:CEDAREDGE
Mailing Address - State:CO
Mailing Address - Zip Code:81413-1044
Mailing Address - Country:US
Mailing Address - Phone:970-850-3161
Mailing Address - Fax:970-856-3021
Practice Address - Street 1:215 W MAIN ST
Practice Address - Street 2:
Practice Address - City:CEDARIDGE
Practice Address - State:CO
Practice Address - Zip Code:81413-1044
Practice Address - Country:US
Practice Address - Phone:970-850-3161
Practice Address - Fax:970-856-3021
Is Sole Proprietor?:No
Enumeration Date:2017-04-06
Last Update Date:2017-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPHA.0011791183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist