Provider Demographics
NPI:1881995041
Name:PRENDERGAST, DECLAN GERARD
Entity type:Individual
Prefix:MR
First Name:DECLAN
Middle Name:GERARD
Last Name:PRENDERGAST
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 1:16405 RIVER RD.
Mailing Address - Street 2:
Mailing Address - City:GUERNEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95446
Mailing Address - Country:US
Mailing Address - Phone:707-869-0613
Mailing Address - Fax:707-869-1945
Practice Address - Street 1:16405 RIVER RD.
Practice Address - Street 2:
Practice Address - City:GUERNEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95446
Practice Address - Country:US
Practice Address - Phone:707-869-0613
Practice Address - Fax:707-869-1945
Is Sole Proprietor?:No
Enumeration Date:2010-11-04
Last Update Date:2010-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA43386183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist