Provider Demographics
NPI:1851867493
Name:BERGUM, JOANNA (PHARMD)
Entity Type:Individual
Prefix:
First Name:JOANNA
Middle Name:
Last Name:BERGUM
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:JOANNA
Other - Middle Name:
Other - Last Name:BISHOP
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHARMD
Mailing Address - Street 1:1015 BELVEDERE PL
Mailing Address - Street 2:
Mailing Address - City:WESTFIELD
Mailing Address - State:IN
Mailing Address - Zip Code:46074-8087
Mailing Address - Country:US
Mailing Address - Phone:463-203-5178
Mailing Address - Fax:317-423-2305
Practice Address - Street 1:320 N NEW JERSEY ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46204-2113
Practice Address - Country:US
Practice Address - Phone:463-203-5178
Practice Address - Fax:317-423-2305
Is Sole Proprietor?:No
Enumeration Date:2018-10-22
Last Update Date:2019-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26021458A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN26021458AOtherSTATE BOARD OF PHARMACY LICENSE