Provider Demographics
NPI:1609528736
Name:FORTIER, CHUCK
Entity Type:Individual
Prefix:
First Name:CHUCK
Middle Name:
Last Name:FORTIER
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:PO BOX 4261
Mailing Address - Street 2:
Mailing Address - City:STURGIS
Mailing Address - State:SD
Mailing Address - Zip Code:57785-4261
Mailing Address - Country:US
Mailing Address - Phone:605-490-0768
Mailing Address - Fax:605-716-1327
Practice Address - Street 1:909 E SAINT PATRICK ST
Practice Address - Street 2:
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57701-5752
Practice Address - Country:US
Practice Address - Phone:605-348-0741
Practice Address - Fax:605-716-1327
Is Sole Proprietor?:No
Enumeration Date:2022-01-20
Last Update Date:2022-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD4614183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist