Provider Demographics
NPI:1811235302
Name:BERGEN, THOMAS CHARLES (PH D)
Entity Type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:CHARLES
Last Name:BERGEN
Suffix:
Gender:M
Credentials:PH D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4730 S FLORIDA AVE
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33813-2181
Mailing Address - Country:US
Mailing Address - Phone:863-646-5471
Mailing Address - Fax:863-701-0950
Practice Address - Street 1:4730 S FLORIDA AVE
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33813-2181
Practice Address - Country:US
Practice Address - Phone:863-646-5471
Practice Address - Fax:863-701-0950
Is Sole Proprietor?:No
Enumeration Date:2013-01-18
Last Update Date:2013-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS18109183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist