Provider Demographics
NPI:1518390574
Name:BORTZ, RYAN
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:BORTZ
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 1:4152 COLUMBUS AVE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55407-3113
Mailing Address - Country:US
Mailing Address - Phone:484-336-6018
Mailing Address - Fax:
Practice Address - Street 1:410 CHURCH ST SE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55455-0222
Practice Address - Country:US
Practice Address - Phone:612-624-7655
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-14
Last Update Date:2021-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARP447728183500000X
MN122537183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty