Provider Demographics
NPI:1457584120
Name:MORTENSEN, DAVID (RPH)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:MORTENSEN
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 1:1311 N MILDRED RD
Mailing Address - Street 2:
Mailing Address - City:CORTEZ
Mailing Address - State:CO
Mailing Address - Zip Code:81321-2231
Mailing Address - Country:US
Mailing Address - Phone:970-564-2193
Mailing Address - Fax:970-564-2197
Practice Address - Street 1:1311 N MILDRED RD
Practice Address - Street 2:
Practice Address - City:CORTEZ
Practice Address - State:CO
Practice Address - Zip Code:81321-2231
Practice Address - Country:US
Practice Address - Phone:970-564-2193
Practice Address - Fax:970-564-2197
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-28
Last Update Date:2014-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO11995183500000X, 1835P1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
No1835P1200XPharmacy Service ProvidersPharmacistPharmacotherapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO11995OtherCOLORADO STATE LICENSE