Provider Demographics
NPI:1912243023
Name:MERCADO, KENNETH (RPH)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:
Last Name:MERCADO
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 1:1231 JANET WAY
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95405-7205
Mailing Address - Country:US
Mailing Address - Phone:707-290-9919
Mailing Address - Fax:
Practice Address - Street 1:100 CALISTOGA RD
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95409-3702
Practice Address - Country:US
Practice Address - Phone:707-539-1711
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-12-17
Last Update Date:2012-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA54879183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist