Provider Demographics
NPI:1962842369
Name:FORTUNATO, RICHARD ERNEST (DR)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:ERNEST
Last Name:FORTUNATO
Suffix:
Gender:M
Credentials:DR
Other - Prefix:DR
Other - First Name:RICK
Other - Middle Name:ERNEST
Other - Last Name:FORTUNATO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PHARMD
Mailing Address - Street 1:PO BOX 984
Mailing Address - Street 2:
Mailing Address - City:NEDERLAND
Mailing Address - State:CO
Mailing Address - Zip Code:80466-0984
Mailing Address - Country:US
Mailing Address - Phone:720-988-3755
Mailing Address - Fax:303-344-2386
Practice Address - Street 1:15200 E COLFAX AVE
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80011-6965
Practice Address - Country:US
Practice Address - Phone:720-988-3755
Practice Address - Fax:303-344-2386
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-28
Last Update Date:2013-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO15806183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO15806OtherSTATE LIS