Provider Demographics
NPI:1962656108
Name:BERGERON, SCOTT RODERICK (PHARMD, RPH)
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:RODERICK
Last Name:BERGERON
Suffix:
Gender:M
Credentials:PHARMD, RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1025 W TRINITY MILLS RD
Mailing Address - Street 2:
Mailing Address - City:CARROLLTON
Mailing Address - State:TX
Mailing Address - Zip Code:75006-1375
Mailing Address - Country:US
Mailing Address - Phone:800-273-3455
Mailing Address - Fax:
Practice Address - Street 1:9159 SE 82ND AVE
Practice Address - Street 2:
Practice Address - City:HAPPY VALLEY
Practice Address - State:OR
Practice Address - Zip Code:97086-3761
Practice Address - Country:US
Practice Address - Phone:503-771-1386
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-11-14
Last Update Date:2020-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX52736183500000X
TN41574183500000X
WAPH60091125183500000X
ORRPH-0010850183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist