Healthcare Provider Details

I. General information

NPI: 1780649145
Provider Name (Legal Business Name): BOB EDWARD MANDERNACK P.PH.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

Provider Other Name: MR. ROBERT EDWARD MANDERNACK

II. Dates (important events)

Enumeration Date: 04/19/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6061 S WILLOW DR
GREENWOOD VILLAGE CO
80111-5103
US

IV. Provider business mailing address

9956 COTTONCREEK DR
LITTLETON CO
80130-3823
US

V. Phone/Fax

Practice location:
  • Phone: 877-839-8121
  • Fax: 877-289-0617
Mailing address:
  • Phone: 303-284-0295
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number13062
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: