Provider Demographics
NPI:1619550928
Name:BERG, JUSTIN MICHAEL (PHARMD)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:MICHAEL
Last Name:BERG
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:70 GATEWAY BLVD
Mailing Address - Street 2:
Mailing Address - City:ROCK SPRINGS
Mailing Address - State:WY
Mailing Address - Zip Code:82901-5709
Mailing Address - Country:US
Mailing Address - Phone:307-382-2536
Mailing Address - Fax:
Practice Address - Street 1:70 GATEWAY BLVD
Practice Address - Street 2:
Practice Address - City:ROCK SPRINGS
Practice Address - State:WY
Practice Address - Zip Code:82901-5709
Practice Address - Country:US
Practice Address - Phone:307-382-2536
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-04
Last Update Date:2021-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY4299183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist