Provider Demographics
NPI:1730785536
Name:MOTTERSHEAD, BRUCE ROBERT
Entity type:Individual
Prefix:
First Name:BRUCE
Middle Name:ROBERT
Last Name:MOTTERSHEAD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 N ROUTE 73 UNIT 36
Mailing Address - Street 2:
Mailing Address - City:WEST BERLIN
Mailing Address - State:NJ
Mailing Address - Zip Code:08091-1429
Mailing Address - Country:US
Mailing Address - Phone:856-768-6688
Mailing Address - Fax:856-768-9779
Practice Address - Street 1:200 N ROUTE 73 UNIT 36
Practice Address - Street 2:
Practice Address - City:WEST BERLIN
Practice Address - State:NJ
Practice Address - Zip Code:08091-1429
Practice Address - Country:US
Practice Address - Phone:856-768-6688
Practice Address - Fax:856-768-9779
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-07
Last Update Date:2020-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RI01762800183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist