Provider Demographics
NPI:1740600121
Name:CISNEROS, LETICIA MARIE (RPH)
Entity type:Individual
Prefix:MS
First Name:LETICIA
Middle Name:MARIE
Last Name:CISNEROS
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1703 WHITEHALL DR UNIT 2E
Mailing Address - Street 2:
Mailing Address - City:LONGMONT
Mailing Address - State:CO
Mailing Address - Zip Code:80504-2545
Mailing Address - Country:US
Mailing Address - Phone:719-331-8105
Mailing Address - Fax:
Practice Address - Street 1:1950 MOUNTAIN VIEW AVE
Practice Address - Street 2:
Practice Address - City:LONGMONT
Practice Address - State:CO
Practice Address - Zip Code:80501-3129
Practice Address - Country:US
Practice Address - Phone:303-651-5332
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-23
Last Update Date:2014-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO17727183500000X
FL32054183500000X
TX35293183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist