Provider Demographics
NPI:1942754841
Name:BERGERON, LISA
Entity Type:Individual
Prefix:DR
First Name:LISA
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 1:268 WEST ST
Mailing Address - Street 2:
Mailing Address - City:KEENE
Mailing Address - State:NH
Mailing Address - Zip Code:03431-2441
Mailing Address - Country:US
Mailing Address - Phone:603-357-2840
Mailing Address - Fax:603-358-6133
Practice Address - Street 1:268 WEST ST
Practice Address - Street 2:
Practice Address - City:KEENE
Practice Address - State:NH
Practice Address - Zip Code:03431-2441
Practice Address - Country:US
Practice Address - Phone:603-357-2840
Practice Address - Fax:603-358-6133
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-08
Last Update Date:2016-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH3822183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist