Provider Demographics
NPI:1760053789
Name:VAN DEN BERG, BRIELLE ANN (PHARMD)
Entity Type:Individual
Prefix:
First Name:BRIELLE
Middle Name:ANN
Last Name:VAN DEN BERG
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2823 N 110TH CT APT 104
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68164-1222
Mailing Address - Country:US
Mailing Address - Phone:402-366-3768
Mailing Address - Fax:
Practice Address - Street 1:12850 L ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68137-2078
Practice Address - Country:US
Practice Address - Phone:402-697-1742
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-09
Last Update Date:2021-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE17146183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist