Provider Demographics
NPI:1003097148
Name:ETTINGER, BERNARD GUY (RPH)
Entity Type:Individual
Prefix:
First Name:BERNARD
Middle Name:GUY
Last Name:ETTINGER
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:756 UPPER GLEN ST
Mailing Address - Street 2:
Mailing Address - City:QUEENSBURY
Mailing Address - State:NY
Mailing Address - Zip Code:12804-2029
Mailing Address - Country:US
Mailing Address - Phone:518-793-3132
Mailing Address - Fax:
Practice Address - Street 1:756 UPPER GLEN ST
Practice Address - Street 2:
Practice Address - City:QUEENSBURY
Practice Address - State:NY
Practice Address - Zip Code:12804-2029
Practice Address - Country:US
Practice Address - Phone:518-793-3132
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-11-16
Last Update Date:2007-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY028068183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00361371Medicaid