Provider Demographics
NPI:1598048902
Name:BERTUCCI, DIANE J (RPH)
Entity Type:Individual
Prefix:MS
First Name:DIANE
Middle Name:J
Last Name:BERTUCCI
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:212 OCELOT DR
Mailing Address - Street 2:
Mailing Address - City:ARABI
Mailing Address - State:LA
Mailing Address - Zip Code:70032-2148
Mailing Address - Country:US
Mailing Address - Phone:504-453-6023
Mailing Address - Fax:
Practice Address - Street 1:800B CANAL ST
Practice Address - Street 2:
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70112-2306
Practice Address - Country:US
Practice Address - Phone:504-528-7099
Practice Address - Fax:504-528-7871
Is Sole Proprietor?:No
Enumeration Date:2011-09-21
Last Update Date:2011-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA14643183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist