Healthcare Provider Details

I. General information

NPI: 1326779869
Provider Name (Legal Business Name): JUSTIN TYLER BLANCHARD-QUINTANAR CPHT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/23/2022
Last Update Date: 06/29/2022
Certification Date: 06/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

660 BANNOCK ST
DENVER CO
80204-4506
US

IV. Provider business mailing address

235 W IRVINGTON PL
DENVER CO
80223-1505
US

V. Phone/Fax

Practice location:
  • Phone: 130-360-2795
  • Fax:
Mailing address:
  • Phone: 172-097-9745
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License Number30080943
License Number StateCO
# 2
Primary TaxonomyY
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License NumberPHAT.0000021
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: