=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609984194
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BLENDE DRUG INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/26/2006
-----------------------------------------------------
Last Update Date | 04/13/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1910 SANTA FE DR
-----------------------------------------------------
City | PUEBLO
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 81006-1452
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 719-542-2477
-----------------------------------------------------
Fax | 719-544-4469
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1910 SANTA FE DR
-----------------------------------------------------
City | PUEBLO
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 81006-1452
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 719-542-2477
-----------------------------------------------------
Fax | 719-544-4469
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | RPH/PRESIDENT
-----------------------------------------------------
Name | JOHN JOSEPH CERNAC
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 719-542-2477
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 333600000X
-----------------------------------------------------
Taxonomy Name | Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | 1040000004
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------