Provider Demographics
NPI:1912485814
Name:BERGEN, BENJAMIN WILLIAM
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:WILLIAM
Last Name:BERGEN
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 1:530 ALBANY ST
Mailing Address - Street 2:
Mailing Address - City:LITTLE FALLS
Mailing Address - State:NY
Mailing Address - Zip Code:13365-1439
Mailing Address - Country:US
Mailing Address - Phone:315-823-0016
Mailing Address - Fax:
Practice Address - Street 1:530 ALBANY ST
Practice Address - Street 2:
Practice Address - City:LITTLE FALLS
Practice Address - State:NY
Practice Address - Zip Code:13365-1439
Practice Address - Country:US
Practice Address - Phone:315-823-0016
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-02
Last Update Date:2022-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY064158183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist