Provider Demographics
NPI:1760722409
Name:BERGERON, JUDITH
Entity Type:Individual
Prefix:
First Name:JUDITH
Middle Name:
Last Name:BERGERON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 FORTUNE BLVD
Mailing Address - Street 2:T1281
Mailing Address - City:MILFORD
Mailing Address - State:MA
Mailing Address - Zip Code:01757-1743
Mailing Address - Country:US
Mailing Address - Phone:508-478-5267
Mailing Address - Fax:
Practice Address - Street 1:250 FORTUNE BLVD
Practice Address - Street 2:T1281
Practice Address - City:MILFORD
Practice Address - State:MA
Practice Address - Zip Code:01757-1743
Practice Address - Country:US
Practice Address - Phone:508-478-5267
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-17
Last Update Date:2013-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPH23485183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist