Provider Demographics
NPI:1164732400
Name:BERGERON, COY (PHARM D)
Entity Type:Individual
Prefix:DR
First Name:COY
Middle Name:
Last Name:BERGERON
Suffix:
Gender:M
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:231 ISERINGHAUSEN RD
Mailing Address - Street 2:
Mailing Address - City:CHURCH POINT
Mailing Address - State:LA
Mailing Address - Zip Code:70525-7511
Mailing Address - Country:US
Mailing Address - Phone:337-278-3706
Mailing Address - Fax:
Practice Address - Street 1:4710 JOHNSTON ST
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70503-4541
Practice Address - Country:US
Practice Address - Phone:337-988-7284
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-20
Last Update Date:2010-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA19214183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist