=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366466799
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | HEIDI J BERTSCH PHARM D, RPH
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/27/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 126 5TH ST N
-----------------------------------------------------
City | BRECKENRIDGE
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 56520-1421
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 218-643-3871
-----------------------------------------------------
Fax | 218-643-1459
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 17626 78TH ST SE
-----------------------------------------------------
City | WAHPETON
-----------------------------------------------------
State | ND
-----------------------------------------------------
Zip | 58075-9311
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 701-642-8997
-----------------------------------------------------
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 | 117774-1
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------