Healthcare Provider Details

I. General information

NPI: 1326132739
Provider Name (Legal Business Name): BERTONCINO ENTERPRISES INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/03/2006
Last Update Date: 06/18/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1107 S MADISON ST STE A STE A
WEBB CITY MO
64870-2831
US

IV. Provider business mailing address

1107 S MADISON ST STE A STE A
WEBB CITY MO
64870-2831
US

V. Phone/Fax

Practice location:
  • Phone: 417-673-4909
  • Fax: 417-673-5697
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number006106
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: DOMINICK J BERTONCINO
Title or Position: OWNER PHARMACIST
Credential: RPH
Phone: 417-673-4909