Provider Demographics
NPI:1316457120
Name:MANRIQUEZ, JOSE ANTONIO (PHARMD)
Entity type:Individual
Prefix:DR
First Name:JOSE
Middle Name:ANTONIO
Last Name:MANRIQUEZ
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 1:222 SOLAR AVE
Mailing Address - Street 2:
Mailing Address - City:MONTE VISTA
Mailing Address - State:CO
Mailing Address - Zip Code:81144-1066
Mailing Address - Country:US
Mailing Address - Phone:719-852-9894
Mailing Address - Fax:
Practice Address - Street 1:222 SOLAR AVE
Practice Address - Street 2:
Practice Address - City:MONTE VISTA
Practice Address - State:CO
Practice Address - Zip Code:81144-1066
Practice Address - Country:US
Practice Address - Phone:719-852-9894
Practice Address - Fax:719-852-9897
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-06
Last Update Date:2017-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO21648183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist