Provider Demographics
NPI:1063544617
Name:BERTELL, LORA ETHELYN (PHARMD)
Entity type:Individual
Prefix:MRS
First Name:LORA
Middle Name:ETHELYN
Last Name:BERTELL
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11829 BANCHARY RD
Mailing Address - Street 2:
Mailing Address - City:BELVIDERE
Mailing Address - State:IL
Mailing Address - Zip Code:61008-7175
Mailing Address - Country:US
Mailing Address - Phone:815-885-4424
Mailing Address - Fax:
Practice Address - Street 1:11829 BANCHARY RD
Practice Address - Street 2:
Practice Address - City:BELVIDERE
Practice Address - State:IL
Practice Address - Zip Code:61008-7175
Practice Address - Country:US
Practice Address - Phone:815-885-4424
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1835X0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835X0200XPharmacy Service ProvidersPharmacistOncology