Provider Demographics
NPI:1578249561
Name:BERTACCHI, GLORIA MARIE
Entity Type:Individual
Prefix:
First Name:GLORIA
Middle Name:MARIE
Last Name:BERTACCHI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 50
Mailing Address - Street 2:
Mailing Address - City:LOOMIS
Mailing Address - State:CA
Mailing Address - Zip Code:95650-0050
Mailing Address - Country:US
Mailing Address - Phone:916-390-1845
Mailing Address - Fax:
Practice Address - Street 1:1333 STATE HIGHWAY 174
Practice Address - Street 2:
Practice Address - City:COLFAX
Practice Address - State:CA
Practice Address - Zip Code:95713-9439
Practice Address - Country:US
Practice Address - Phone:916-390-1845
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-23
Last Update Date:2023-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA31805183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist