Provider Demographics
NPI:1114369428
Name:BERGIN, RYAN ANTHONY (PHARMD)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:ANTHONY
Last Name:BERGIN
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 1:9006 LEXINGTON AVE NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87112-1242
Mailing Address - Country:US
Mailing Address - Phone:505-379-5608
Mailing Address - Fax:
Practice Address - Street 1:11200 MONTGOMERY BLVD NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87111-2677
Practice Address - Country:US
Practice Address - Phone:505-298-7477
Practice Address - Fax:505-299-8617
Is Sole Proprietor?:No
Enumeration Date:2013-07-28
Last Update Date:2013-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMRP00008034183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist