Provider Demographics
NPI:1255967964
Name:BERGMAN, MOLLY JO (PHARMD)
Entity type:Individual
Prefix:
First Name:MOLLY
Middle Name:JO
Last Name:BERGMAN
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 1:5072 NIEMANVILLE TRL
Mailing Address - Street 2:
Mailing Address - City:LITCHFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62056-4613
Mailing Address - Country:US
Mailing Address - Phone:217-710-5522
Mailing Address - Fax:
Practice Address - Street 1:274 N BROAD ST
Practice Address - Street 2:
Practice Address - City:CARLINVILLE
Practice Address - State:IL
Practice Address - Zip Code:62626-1371
Practice Address - Country:US
Practice Address - Phone:217-854-4022
Practice Address - Fax:217-854-4300
Is Sole Proprietor?:No
Enumeration Date:2020-03-14
Last Update Date:2020-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051.299495183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist