Provider Demographics
NPI:1457733669
Name:BERGENDAHL, ELLEN MARIE
Entity Type:Individual
Prefix:
First Name:ELLEN
Middle Name:MARIE
Last Name:BERGENDAHL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ELLEN
Other - Middle Name:MARIE
Other - Last Name:SCHWARTZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RPH
Mailing Address - Street 1:1725 NORTHPORT DR
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53704-3025
Mailing Address - Country:US
Mailing Address - Phone:608-241-7001
Mailing Address - Fax:
Practice Address - Street 1:1725 NORTHPORT DR
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53704-3025
Practice Address - Country:US
Practice Address - Phone:608-241-7001
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-24
Last Update Date:2015-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI17922-40183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist