Provider Demographics
NPI:1962900696
Name:BERTUCCI, LAURA (RPH)
Entity type:Individual
Prefix:MRS
First Name:LAURA
Middle Name:
Last Name:BERTUCCI
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:375-3 W STATE ROAD 130
Mailing Address - Street 2:
Mailing Address - City:VALPARAISO
Mailing Address - State:IN
Mailing Address - Zip Code:46385-8368
Mailing Address - Country:US
Mailing Address - Phone:219-741-6247
Mailing Address - Fax:
Practice Address - Street 1:1500 S LAKE PARK AVE
Practice Address - Street 2:
Practice Address - City:HOBART
Practice Address - State:IN
Practice Address - Zip Code:46342-6638
Practice Address - Country:US
Practice Address - Phone:219-947-6480
Practice Address - Fax:219-947-6497
Is Sole Proprietor?:No
Enumeration Date:2018-01-29
Last Update Date:2018-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26019057A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist