Provider Demographics
NPI:1558775239
Name:BERGSTROM, AMY FILHART (RPH)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:FILHART
Last Name:BERGSTROM
Suffix:
Gender:F
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:PO BOX 744
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85380-0744
Mailing Address - Country:US
Mailing Address - Phone:623-486-5536
Mailing Address - Fax:
Practice Address - Street 1:8332 W THUNDERBIRD RD
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85381-4822
Practice Address - Country:US
Practice Address - Phone:623-776-3006
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-20
Last Update Date:2014-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZS10126183500000X
MI5302027914183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist