Provider Demographics
NPI:1588652978
Name:BERGHOFF, GREG B (RPH)
Entity Type:Individual
Prefix:
First Name:GREG
Middle Name:B
Last Name:BERGHOFF
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 1:4402 E STATE BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46815-6917
Mailing Address - Country:US
Mailing Address - Phone:260-969-7846
Mailing Address - Fax:260-482-9476
Practice Address - Street 1:4402 E STATE BLVD
Practice Address - Street 2:
Practice Address - City:FT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46815-6917
Practice Address - Country:US
Practice Address - Phone:260-969-7846
Practice Address - Fax:260-482-9476
Is Sole Proprietor?:No
Enumeration Date:2005-10-10
Last Update Date:2018-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26014462A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist