=====================================================
General NPI Number Information
=====================================================
NPI Number | 1336462761
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BRET A. KOERTGE PHARMD, PHD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/12/2010
-----------------------------------------------------
Last Update Date | 11/06/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 115 W BOND ST STE P
-----------------------------------------------------
City | ASTORIA
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97103-6009
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-468-3146
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2095 EXETER RD UNIT 80-454
-----------------------------------------------------
City | GERMANTOWN
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 38138-3963
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 901-687-7170
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 33685
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | S024593
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | T-14431
-----------------------------------------------------
License Number State | MS
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 21467
-----------------------------------------------------
License Number State | AL
-----------------------------------------------------
Taxonomy #5
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 66305
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #6
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 22079
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------
Taxonomy #7
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | R-17333
-----------------------------------------------------
License Number State | OK
-----------------------------------------------------
Taxonomy #8
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | RPH-0017930
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------
Taxonomy #9
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 202218476
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------
Taxonomy #10
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 17987
-----------------------------------------------------
License Number State | NE
-----------------------------------------------------
Taxonomy #11
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 26023762A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------