Healthcare Provider Details

I. General information

NPI: 1568067239
Provider Name (Legal Business Name): BERTRAND FONTEM PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/01/2020
Last Update Date: 12/01/2020
Certification Date: 12/01/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1003 N US HIGHWAY 65
CARROLLTON MO
64633-1972
US

IV. Provider business mailing address

1003 N US HIGHWAY 65
CARROLLTON MO
64633-1972
US

V. Phone/Fax

Practice location:
  • Phone: 660-542-1111
  • Fax: 660-542-3051
Mailing address:
  • Phone: 660-542-1111
  • Fax: 660-542-3051

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number2018031227
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: