Provider Demographics
NPI:1437759834
Name:BERGERON, OLIVIA
Entity Type:Individual
Prefix:
First Name:OLIVIA
Middle Name:
Last Name:BERGERON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:988 KRISTEN DR
Mailing Address - Street 2:
Mailing Address - City:HAMBURG
Mailing Address - State:AR
Mailing Address - Zip Code:71646-3344
Mailing Address - Country:US
Mailing Address - Phone:870-853-6292
Mailing Address - Fax:
Practice Address - Street 1:1001 HIGHWAY 65 S
Practice Address - Street 2:
Practice Address - City:MC GEHEE
Practice Address - State:AR
Practice Address - Zip Code:71654-9417
Practice Address - Country:US
Practice Address - Phone:870-853-6292
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-27
Last Update Date:2020-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPD14145183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist