Provider Demographics
NPI:1275827024
Name:BERTELSEN, ERIC RAYMOND
Entity Type:Individual
Prefix:MR
First Name:ERIC
Middle Name:RAYMOND
Last Name:BERTELSEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4825 MARBURG AVE UNIT A
Mailing Address - Street 2:T-1447
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45209-5013
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4825 MARBURG AVE UNIT A
Practice Address - Street 2:T-1447
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45209-5013
Practice Address - Country:US
Practice Address - Phone:513-631-5717
Practice Address - Fax:513-631-5717
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-08
Last Update Date:2011-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03114774183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist