Provider Demographics
NPI:1144823998
Name:FONTANILLA, ROMMEL
Entity type:Individual
Prefix:
First Name:ROMMEL
Middle Name:
Last Name:FONTANILLA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3063 BRIGHTON BLVD UNIT 721
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80216-5294
Mailing Address - Country:US
Mailing Address - Phone:253-347-2341
Mailing Address - Fax:
Practice Address - Street 1:65 TEJON ST
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80223-1221
Practice Address - Country:US
Practice Address - Phone:303-778-3100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-16
Last Update Date:2020-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO23200183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist