Provider Demographics
NPI:1275336174
Name:BLENDE DRUG INC
Entity type:Organization
Organization Name:BLENDE DRUG INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PIC/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:CERNAC
Authorized Official - Suffix:SR
Authorized Official - Credentials:RPH
Authorized Official - Phone:719-542-2477
Mailing Address - Street 1:1910 SANTA FE DR
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81006-1452
Mailing Address - Country:US
Mailing Address - Phone:719-542-2477
Mailing Address - Fax:719-544-4469
Practice Address - Street 1:1910 SANTA FE DR
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81006-1452
Practice Address - Country:US
Practice Address - Phone:719-542-2477
Practice Address - Fax:719-544-4469
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-03-28
Last Update Date:2025-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO03094299Medicaid