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General NPI Number Information
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NPI Number | 1912243023
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Entity Type | Individual
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Provider Name | KENNETH MERCADO RPH
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Gender | Male
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Dates
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Enumeration Date | 12/17/2012
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Last Update Date | 12/17/2012
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Provider Practice Location Address
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Address Line | 100 CALISTOGA RD
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City | SANTA ROSA
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State | CA
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Zip | 95409-3702
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Country | US
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Telephone | 707-539-1711
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Fax |
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Provider Business Mailing Address
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Address Line | 1231 JANET WAY
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City | SANTA ROSA
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State | CA
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Zip | 95405-7205
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Country | US
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Telephone | 707-290-9919
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 183500000X
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Taxonomy Name | Pharmacist
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License Number | 54879
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License Number State | CA
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