Provider Demographics
NPI:1962507137
Name:AUTREY, BERTA LINDA (RPH)
Entity Type:Individual
Prefix:
First Name:BERTA
Middle Name:LINDA
Last Name:AUTREY
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:LINDA
Other - Middle Name:G
Other - Last Name:AUTREY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RPH
Mailing Address - Street 1:134 PALO ALTO DR
Mailing Address - Street 2:
Mailing Address - City:BROWNSVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:78521-2609
Mailing Address - Country:US
Mailing Address - Phone:956-542-6574
Mailing Address - Fax:
Practice Address - Street 1:1205 CENTRAL BLVD
Practice Address - Street 2:
Practice Address - City:BROWNSVILLE
Practice Address - State:TX
Practice Address - Zip Code:78520-7531
Practice Address - Country:US
Practice Address - Phone:956-548-0801
Practice Address - Fax:956-548-0802
Is Sole Proprietor?:No
Enumeration Date:2006-09-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX23294183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX23294OtherPHARMACIST LICENSE NUMBER