Provider Demographics
NPI:1881948180
Name:BERTUCCI, NATHAN JOHN (PHARMD)
Entity type:Individual
Prefix:
First Name:NATHAN
Middle Name:JOHN
Last Name:BERTUCCI
Suffix:
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 1:1191 WESTOWNE DR
Mailing Address - Street 2:
Mailing Address - City:NEENAH
Mailing Address - State:WI
Mailing Address - Zip Code:54956-2176
Mailing Address - Country:US
Mailing Address - Phone:920-725-3152
Mailing Address - Fax:920-725-3238
Practice Address - Street 1:1578 APPLETON RD
Practice Address - Street 2:
Practice Address - City:MENASHA
Practice Address - State:WI
Practice Address - Zip Code:54952-1104
Practice Address - Country:US
Practice Address - Phone:920-722-1895
Practice Address - Fax:920-722-3195
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-08
Last Update Date:2020-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302038799183500000X
WI3336C0003X
WI16571-40183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy