Provider Demographics
NPI:1780649145
Name:MANDERNACK, BOB EDWARD (PPH)
Entity Type:Individual
Prefix:MR
First Name:BOB
Middle Name:EDWARD
Last Name:MANDERNACK
Suffix:
Gender:M
Credentials:PPH
Other - Prefix:MR
Other - First Name:ROBERT
Other - Middle Name:EDWARD
Other - Last Name:MANDERNACK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:9956 COTTONCREEK DR
Mailing Address - Street 2:
Mailing Address - City:LITTLETON
Mailing Address - State:CO
Mailing Address - Zip Code:80130-3823
Mailing Address - Country:US
Mailing Address - Phone:303-284-0295
Mailing Address - Fax:
Practice Address - Street 1:6061 S WILLOW DR
Practice Address - Street 2:
Practice Address - City:GREENWOOD VILLAGE
Practice Address - State:CO
Practice Address - Zip Code:80111-5103
Practice Address - Country:US
Practice Address - Phone:877-839-8121
Practice Address - Fax:877-289-0617
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA13062183500000X
ID183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered183500000XPharmacy Service ProvidersPharmacist