Provider Demographics
NPI:1568051449
Name:FORTANELLI, AGUSTIN (CPHT)
Entity Type:Individual
Prefix:
First Name:AGUSTIN
Middle Name:
Last Name:FORTANELLI
Suffix:
Gender:M
Credentials:CPHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:306 N MECHANIC ST
Mailing Address - Street 2:
Mailing Address - City:EL CAMPO
Mailing Address - State:TX
Mailing Address - Zip Code:77437-4420
Mailing Address - Country:US
Mailing Address - Phone:979-578-8609
Mailing Address - Fax:
Practice Address - Street 1:306 N MECHANIC ST
Practice Address - Street 2:
Practice Address - City:EL CAMPO
Practice Address - State:TX
Practice Address - Zip Code:77437-4420
Practice Address - Country:US
Practice Address - Phone:254-368-4448
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-14
Last Update Date:2021-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX30106564183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician