Provider Demographics
NPI:1093092314
Name:BERGSTROM, KAREN MARIE (RPH)
Entity Type:Individual
Prefix:
First Name:KAREN
Middle Name:MARIE
Last Name:BERGSTROM
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 1:280 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80911-1712
Mailing Address - Country:US
Mailing Address - Phone:719-390-9123
Mailing Address - Fax:719-392-5149
Practice Address - Street 1:280 MAIN ST
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80911-1712
Practice Address - Country:US
Practice Address - Phone:719-390-9123
Practice Address - Fax:719-390-5149
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-15
Last Update Date:2011-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO14792183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist