Provider Demographics
NPI:1649286832
Name:GOLDBERG, BRUCE S
Entity type:Individual
Prefix:
First Name:BRUCE
Middle Name:S
Last Name:GOLDBERG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 241148
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68124-5148
Mailing Address - Country:US
Mailing Address - Phone:402-968-4574
Mailing Address - Fax:
Practice Address - Street 1:1314 RIDGEWOOD AVE
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68124-1315
Practice Address - Country:US
Practice Address - Phone:402-968-4574
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE9780183500000X
IA16516183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist