Provider Demographics
NPI:1083231906
Name:BERGQUIST, BETSEY (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:BETSEY
Middle Name:
Last Name:BERGQUIST
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 1:4040 MARTIN LUTHER KING BLVD
Mailing Address - Street 2:STE B
Mailing Address - City:NORTH LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89032
Mailing Address - Country:US
Mailing Address - Phone:702-625-6624
Mailing Address - Fax:
Practice Address - Street 1:4040 MARTIN LUTHER KING BLVD
Practice Address - Street 2:STE B
Practice Address - City:NORTH LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89032
Practice Address - Country:US
Practice Address - Phone:702-625-6624
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-26
Last Update Date:2020-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV203961835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist