Healthcare Provider Details

I. General information

NPI: 1578521134
Provider Name (Legal Business Name): CHARLES R FORTNER RPH
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/03/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1806 S LIMERICK DR
SPOKANE VALLEY WA
99037-9234
US

IV. Provider business mailing address

1806 S LIMERICK DR
SPOKANE VALLEY WA
99037-9234
US

V. Phone/Fax

Practice location:
  • Phone: 509-489-4500
  • Fax: 509-489-4527
Mailing address:
  • Phone: 509-489-4500
  • Fax: 509-489-4527

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P1200X
TaxonomyPharmacotherapy Pharmacist
License NumberPH00011107
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: