Provider Demographics
NPI:1851675391
Name:BLACK, HERNAN G (PHARMD)
Entity Type:Individual
Prefix:
First Name:HERNAN
Middle Name:G
Last Name:BLACK
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2727 W NORTH AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53208-1549
Mailing Address - Country:US
Mailing Address - Phone:414-933-9150
Mailing Address - Fax:414-933-1620
Practice Address - Street 1:2727 W NORTH AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53208-1549
Practice Address - Country:US
Practice Address - Phone:414-933-9150
Practice Address - Fax:414-933-1620
Is Sole Proprietor?:No
Enumeration Date:2011-10-03
Last Update Date:2011-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI16362183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist