Provider Demographics
NPI:1356051148
Name:DOMINGUEZ, DENNIS (RPH)
Entity type:Individual
Prefix:
First Name:DENNIS
Middle Name:
Last Name:DOMINGUEZ
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 1:1300 DEXTER ST
Mailing Address - Street 2:
Mailing Address - City:FORT LUPTON
Mailing Address - State:CO
Mailing Address - Zip Code:80621-1501
Mailing Address - Country:US
Mailing Address - Phone:303-857-0136
Mailing Address - Fax:
Practice Address - Street 1:1300 DEXTER ST
Practice Address - Street 2:
Practice Address - City:FORT LUPTON
Practice Address - State:CO
Practice Address - Zip Code:80621-1501
Practice Address - Country:US
Practice Address - Phone:303-857-0136
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-02
Last Update Date:2022-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPHA.0024298183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist