Provider Demographics
NPI:1356426217
Name:BERGOLLA, LUIS ANGEL (PHARM D)
Entity type:Individual
Prefix:
First Name:LUIS
Middle Name:ANGEL
Last Name:BERGOLLA
Suffix:
Gender:M
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14117 SW 51ST CT
Mailing Address - Street 2:
Mailing Address - City:MIRAMAR
Mailing Address - State:FL
Mailing Address - Zip Code:33027-5971
Mailing Address - Country:US
Mailing Address - Phone:305-816-5854
Mailing Address - Fax:
Practice Address - Street 1:5850 NW 183RD ST
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33015-6023
Practice Address - Country:US
Practice Address - Phone:305-819-0705
Practice Address - Fax:305-819-0174
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS41487183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist