MEDICARE: BERTRAND FONTEM PHARMD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	2018031227	MO

General Provider Information

NPI Number	:	1568067239
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BERTRAND FONTEM PHARMD

Provider Business Mailing Address
First Line	:	1003 N US HIGHWAY 65
Second Line	:
City	:	CARROLLTON
State	:	MO
Zip	:	64633-1972
Country	:	US
Telephone Number	:	660-542-1111
Fax Number	:	660-542-3051

Provider Business Practice Location Address
First Line	:	1003 N US HIGHWAY 65
Second Line	:
City	:	CARROLLTON
State	:	MO
Zip	:	64633-1972
Country	:	US
Telephone Number	:	660-542-1111
Fax Number	:	660-542-3051

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/01/2020
Last Update Date	:	12/01/2020

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Directions to “ BERTRAND FONTEM PHARMD” Practice Location

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