Provider Demographics
NPI:1376870204
Name:HERNANDEZ, MARIO M (RPH)
Entity Type:Individual
Prefix:
First Name:MARIO
Middle Name:M
Last Name:HERNANDEZ
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 1:5669 RIVERDALE AVE
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10471-2105
Mailing Address - Country:US
Mailing Address - Phone:718-543-7500
Mailing Address - Fax:718-543-1421
Practice Address - Street 1:5669 RIVERDALE AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10471-2105
Practice Address - Country:US
Practice Address - Phone:718-543-7500
Practice Address - Fax:718-543-1421
Is Sole Proprietor?:No
Enumeration Date:2009-11-13
Last Update Date:2023-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY040336183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist