Provider Demographics
NPI:1750942629
Name:HERNANDEZ, ROBERT JOHN
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:JOHN
Last Name:HERNANDEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12847 N 93RD DR
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85381-4932
Mailing Address - Country:US
Mailing Address - Phone:602-486-4963
Mailing Address - Fax:
Practice Address - Street 1:14111 N PRASADA GATEWAY AVE
Practice Address - Street 2:
Practice Address - City:SURPRISE
Practice Address - State:AZ
Practice Address - Zip Code:85388-2201
Practice Address - Country:US
Practice Address - Phone:623-282-3208
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-21
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZS023466183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist