Provider Demographics
NPI:1033388996
Name:BORTZ, ROBERT ALAN (RPH)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:ALAN
Last Name:BORTZ
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 1:2350 S FERDON BLVD
Mailing Address - Street 2:
Mailing Address - City:CRESTVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:32536-8461
Mailing Address - Country:US
Mailing Address - Phone:850-689-0568
Mailing Address - Fax:
Practice Address - Street 1:2350 S FERDON BLVD
Practice Address - Street 2:
Practice Address - City:CRESTVIEW
Practice Address - State:FL
Practice Address - Zip Code:32536-8461
Practice Address - Country:US
Practice Address - Phone:850-689-0568
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-02-25
Last Update Date:2008-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS36925183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist