Provider Demographics
NPI:1134460231
Name:BERGERON, BRYCE MATTHEW (RPH)
Entity Type:Individual
Prefix:MR
First Name:BRYCE
Middle Name:MATTHEW
Last Name:BERGERON
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1015 S BROADWAY
Mailing Address - Street 2:SUITE 3
Mailing Address - City:MINOT
Mailing Address - State:ND
Mailing Address - Zip Code:58701-4667
Mailing Address - Country:US
Mailing Address - Phone:701-852-4181
Mailing Address - Fax:701-839-6019
Practice Address - Street 1:1015 S BROADWAY
Practice Address - Street 2:SUITE 3
Practice Address - City:MINOT
Practice Address - State:ND
Practice Address - Zip Code:58701-4667
Practice Address - Country:US
Practice Address - Phone:701-852-4181
Practice Address - Fax:701-839-6019
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-14
Last Update Date:2013-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND4463183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist