Provider Demographics
NPI:1699060574
Name:BERTCH, JACK LEE (RPH)
Entity type:Individual
Prefix:MR
First Name:JACK
Middle Name:LEE
Last Name:BERTCH
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:JACK
Other - Middle Name:
Other - Last Name:BERTCH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:9157 E VOLTAIRE DR
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85260-4285
Mailing Address - Country:US
Mailing Address - Phone:480-580-6988
Mailing Address - Fax:
Practice Address - Street 1:16806 N 7TH ST
Practice Address - Street 2:T-2236
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85022-2662
Practice Address - Country:US
Practice Address - Phone:602-794-3602
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-18
Last Update Date:2011-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZS006407183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist