Provider Demographics
NPI:1740693753
Name:BERGERON, RICK
Entity type:Individual
Prefix:
First Name:RICK
Middle Name:
Last Name:BERGERON
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 1:12151 NANDUA SHORES DR
Mailing Address - Street 2:
Mailing Address - City:PAINTER
Mailing Address - State:VA
Mailing Address - Zip Code:23420-3222
Mailing Address - Country:US
Mailing Address - Phone:757-710-8526
Mailing Address - Fax:
Practice Address - Street 1:25096 LANKFORD HIGHWAY
Practice Address - Street 2:
Practice Address - City:ONLEY
Practice Address - State:VA
Practice Address - Zip Code:23418
Practice Address - Country:US
Practice Address - Phone:757-787-7154
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-06
Last Update Date:2014-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202208491183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist