Provider Demographics
NPI:1093225708
Name:BERGSMA, RANDY J (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:RANDY
Middle Name:J
Last Name:BERGSMA
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4495 WALLEYE DR SW
Mailing Address - Street 2:
Mailing Address - City:WALKER
Mailing Address - State:MI
Mailing Address - Zip Code:49534-6574
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1223 PHOENIX ST
Practice Address - Street 2:
Practice Address - City:SOUTH HAVEN
Practice Address - State:MI
Practice Address - Zip Code:49090-7911
Practice Address - Country:US
Practice Address - Phone:269-639-3510
Practice Address - Fax:269-639-3565
Is Sole Proprietor?:No
Enumeration Date:2017-10-08
Last Update Date:2017-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI53020419611835P1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P1200XPharmacy Service ProvidersPharmacistPharmacotherapy