Provider Demographics
NPI:1326779869
Name:BLANCHARD-QUINTANAR, JUSTIN TYLER (CPHT)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:TYLER
Last Name:BLANCHARD-QUINTANAR
Suffix:
Gender:M
Credentials:CPHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:235 W IRVINGTON PL
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80223-1505
Mailing Address - Country:US
Mailing Address - Phone:172-097-9745
Mailing Address - Fax:
Practice Address - Street 1:660 BANNOCK ST
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80204-4506
Practice Address - Country:US
Practice Address - Phone:130-360-2795
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-23
Last Update Date:2022-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO30080943183700000X
COPHAT.0000021183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician