Provider Demographics
NPI:1568067239
Name:FONTEM, BERTRAND (PHARMD)
Entity Type:Individual
Prefix:
First Name:BERTRAND
Middle Name:
Last Name:FONTEM
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1003 N US HIGHWAY 65
Mailing Address - Street 2:
Mailing Address - City:CARROLLTON
Mailing Address - State:MO
Mailing Address - Zip Code:64633-1972
Mailing Address - Country:US
Mailing Address - Phone:660-542-1111
Mailing Address - Fax:660-542-3051
Practice Address - Street 1:1003 N US HIGHWAY 65
Practice Address - Street 2:
Practice Address - City:CARROLLTON
Practice Address - State:MO
Practice Address - Zip Code:64633-1972
Practice Address - Country:US
Practice Address - Phone:660-542-1111
Practice Address - Fax:660-542-3051
Is Sole Proprietor?:No
Enumeration Date:2020-12-01
Last Update Date:2020-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2018031227183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist