Provider Demographics
NPI:1770850927
Name:BERGERON, HOLLY (RPH)
Entity Type:Individual
Prefix:
First Name:HOLLY
Middle Name:
Last Name:BERGERON
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1505 E 86TH ST
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46240-2392
Mailing Address - Country:US
Mailing Address - Phone:317-254-9206
Mailing Address - Fax:
Practice Address - Street 1:1505 E 86TH STREET
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46240
Practice Address - Country:US
Practice Address - Phone:317-254-9206
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-16
Last Update Date:2011-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS33969183500000X
IN26020424A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist