Healthcare Provider Details

I. General information

NPI: 1558041533
Provider Name (Legal Business Name): MRS. REBECCA ANN BERGWALL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/24/2023
Last Update Date: 07/24/2023
Certification Date: 07/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1330 US 41 W
ISHPEMING MI
49849-3152
US

IV. Provider business mailing address

136 TIMBER LN
MARQUETTE MI
49855-8801
US

V. Phone/Fax

Practice location:
  • Phone: 906-249-9825
  • Fax:
Mailing address:
  • Phone: 906-249-9825
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number5302410927
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: