Provider Demographics
NPI:1922593698
Name:BERTAGNOLLI, CHARLES JR (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:
Last Name:BERTAGNOLLI
Suffix:JR
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 1:4976 SKYLINE DR
Mailing Address - Street 2:
Mailing Address - City:ROELAND PARK
Mailing Address - State:KS
Mailing Address - Zip Code:66205-1148
Mailing Address - Country:US
Mailing Address - Phone:573-821-6418
Mailing Address - Fax:
Practice Address - Street 1:4976 SKYLINE DR
Practice Address - Street 2:
Practice Address - City:ROELAND PARK
Practice Address - State:KS
Practice Address - Zip Code:66205-1148
Practice Address - Country:US
Practice Address - Phone:573-821-6418
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-26
Last Update Date:2018-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2018021529183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist