Provider Demographics
NPI:1104293174
Name:BORTLE, RICHARD (RPH)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:
Last Name:BORTLE
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1925 MARKETPLACE DR SE
Mailing Address - Street 2:
Mailing Address - City:CALEDONIA
Mailing Address - State:MI
Mailing Address - Zip Code:49316-8511
Mailing Address - Country:US
Mailing Address - Phone:616-528-2008
Mailing Address - Fax:
Practice Address - Street 1:1925 MARKETPLACE DR SE
Practice Address - Street 2:
Practice Address - City:CALEDONIA
Practice Address - State:MI
Practice Address - Zip Code:49316-8511
Practice Address - Country:US
Practice Address - Phone:810-714-0975
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-26
Last Update Date:2015-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302025664183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist