Healthcare Provider Details

I. General information

NPI: 1811092372
Provider Name (Legal Business Name): MRS. JACQUELINE FRANCES BERGERON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/13/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

213 HOSPITAL RD WINN DIXIE PHARMACY #1572
NEW ROADS LA
70760
US

IV. Provider business mailing address

412 PECAN ST
NEW ROADS LA
70760
US

V. Phone/Fax

Practice location:
  • Phone: 225-638-5151
  • Fax: 225-638-5148
Mailing address:
  • Phone: 225-618-0635
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number11853
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: