Provider Demographics
NPI:1609881242
Name:BERGUM DRUG
Entity Type:Organization
Organization Name:BERGUM DRUG
Other - Org Name:BERGUM DRUG
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RON
Authorized Official - Middle Name:
Authorized Official - Last Name:BERGUM
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:406-443-0505
Mailing Address - Street 1:PO BOX 6487
Mailing Address - Street 2:
Mailing Address - City:HELENA
Mailing Address - State:MT
Mailing Address - Zip Code:59604-6487
Mailing Address - Country:US
Mailing Address - Phone:406-443-0505
Mailing Address - Fax:406-449-6273
Practice Address - Street 1:2600 WINNE AVE
Practice Address - Street 2:
Practice Address - City:HELENA
Practice Address - State:MT
Practice Address - Zip Code:59601-4900
Practice Address - Country:US
Practice Address - Phone:406-443-0506
Practice Address - Fax:406-449-6273
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-30
Last Update Date:2014-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X
MT203753336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0000211822Medicaid
2050293OtherPK
MT0000211822Medicaid