Provider Demographics
NPI:1275664260
Name:BERTOLA, MARIE G (RPH)
Entity Type:Individual
Prefix:MRS
First Name:MARIE
Middle Name:G
Last Name:BERTOLA
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28 BREEZEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:ORCHARD PARK
Mailing Address - State:NY
Mailing Address - Zip Code:14127-4828
Mailing Address - Country:US
Mailing Address - Phone:716-667-7759
Mailing Address - Fax:
Practice Address - Street 1:424 ELMWOOD AVE
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14222-2210
Practice Address - Country:US
Practice Address - Phone:716-882-3111
Practice Address - Fax:716-882-3400
Is Sole Proprietor?:No
Enumeration Date:2007-03-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY042492183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist