Provider Demographics
NPI:1831679315
Name:BERGQUIST, KARLY MACKENZIE (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:KARLY
Middle Name:MACKENZIE
Last Name:BERGQUIST
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 1:3033 BLAKE ST UNIT 112
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80205-2331
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12850 E MONTVIEW BLVD
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80045-2605
Practice Address - Country:US
Practice Address - Phone:303-724-1234
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-15
Last Update Date:2018-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO22315183500000X, 1835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
No183500000XPharmacy Service ProvidersPharmacist