Basic Information
Provider Information | |||||||||
NPI: | 1003010885 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | CEDENO | ||||||||
FirstName: | CESAR | ||||||||
MiddleName: | ENRIQUE | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | PHARM.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 132 SW PEACOCK BLVD | ||||||||
Address2: | #203 | ||||||||
City: | SAINT LUCIE WEST | ||||||||
State: | FL | ||||||||
PostalCode: | 349864500 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: |   | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1705 US HIGHWAY 1 | ||||||||
Address2: |   | ||||||||
City: | VERO BEACH | ||||||||
State: | FL | ||||||||
PostalCode: | 329605544 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7725691414 | ||||||||
FaxNumber: | 7725685181 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/13/2007 | ||||||||
LastUpdateDate: | 07/08/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183500000X | PS40214 | FL | Y |   | Pharmacy Service Providers | Pharmacist |   |
ID Information
ID | Type | State | Issuer | Description | PS40214 | 01 | FL | FLORIDA PHARMACY LICENSE | OTHER |