Provider Demographics
NPI:1851868160
Name:CERNAC, JOHN JOSEPH (PHARMACIST)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:JOSEPH
Last Name:CERNAC
Suffix:
Gender:M
Credentials:PHARMACIST
Other - Prefix:
Other - First Name:JOHN
Other - Middle Name:JOSEPH
Other - Last Name:CERNAC
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHARMACIST
Mailing Address - Street 1:1910 SANTA FE DR
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81006-1452
Mailing Address - Country:US
Mailing Address - Phone:719-542-2477
Mailing Address - Fax:719-544-4469
Practice Address - Street 1:1910 SANTA FE DR
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81006-1452
Practice Address - Country:US
Practice Address - Phone:719-542-2477
Practice Address - Fax:719-544-4469
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-25
Last Update Date:2023-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO8407183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO03094299Medicaid