Healthcare Provider Details

I. General information

NPI: 1659128536
Provider Name (Legal Business Name): CARLOS JOAQUIN CISNEROS PHARM D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/30/2024
Last Update Date: 04/30/2024
Certification Date: 04/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1017 N MARKET PLZ
PUEBLO WEST CO
81007-1502
US

IV. Provider business mailing address

103 ARGYLE AVE
PUEBLO CO
81004-1007
US

V. Phone/Fax

Practice location:
  • Phone: 719-547-2913
  • Fax:
Mailing address:
  • Phone: 719-214-7637
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number19562
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: