Provider Demographics
NPI:1669872842
Name:BERTRAND, EMMANUEL VICTOR
Entity type:Individual
Prefix:MR
First Name:EMMANUEL
Middle Name:VICTOR
Last Name:BERTRAND
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 1:3715 UNIVERSITY BLVD W
Mailing Address - Street 2:
Mailing Address - City:KENSINGTON
Mailing Address - State:MD
Mailing Address - Zip Code:20895-2123
Mailing Address - Country:US
Mailing Address - Phone:301-962-5975
Mailing Address - Fax:301-962-4843
Practice Address - Street 1:3715 UNIVERSITY BLVD W
Practice Address - Street 2:
Practice Address - City:KENSINGTON
Practice Address - State:MD
Practice Address - Zip Code:20895-2123
Practice Address - Country:US
Practice Address - Phone:301-962-5975
Practice Address - Fax:301-962-4843
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-25
Last Update Date:2014-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD13099183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist