Provider Demographics
NPI:1821425422
Name:BERTRAND, MARILYN SAMPOGNARO (RPH)
Entity Type:Individual
Prefix:MRS
First Name:MARILYN
Middle Name:SAMPOGNARO
Last Name:BERTRAND
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 1:305 SUMMER LAKE DR
Mailing Address - Street 2:
Mailing Address - City:BOSSIER CITY
Mailing Address - State:LA
Mailing Address - Zip Code:71112-8785
Mailing Address - Country:US
Mailing Address - Phone:318-549-2107
Mailing Address - Fax:318-549-2110
Practice Address - Street 1:4918 BARKSDALE BLVD
Practice Address - Street 2:
Practice Address - City:BOSSIER CITY
Practice Address - State:LA
Practice Address - Zip Code:71112-4555
Practice Address - Country:US
Practice Address - Phone:318-549-2107
Practice Address - Fax:318-549-2110
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-27
Last Update Date:2013-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA14069183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist