Provider Demographics
NPI:1104151455
Name:CORDOVA, ANTONIO (PHARMD)
Entity type:Individual
Prefix:
First Name:ANTONIO
Middle Name:
Last Name:CORDOVA
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3670 PARKER BLVD
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81008-2285
Mailing Address - Country:US
Mailing Address - Phone:719-595-5367
Mailing Address - Fax:
Practice Address - Street 1:3670 PARKER BLVD
Practice Address - Street 2:SUITE 200
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81008-2207
Practice Address - Country:US
Practice Address - Phone:719-595-5367
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-05
Last Update Date:2014-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO16928183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist