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General NPI Number Information
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NPI Number | 1255967964
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Entity Type | Individual
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Provider Name | MOLLY JO BERGMAN PHARMD
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Gender | Female
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Dates
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Enumeration Date | 03/14/2020
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Last Update Date | 03/14/2020
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Provider Practice Location Address
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Address Line | 274 N BROAD ST
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City | CARLINVILLE
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State | IL
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Zip | 62626-1371
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Country | US
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Telephone | 217-854-4022
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Fax | 217-854-4300
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Provider Business Mailing Address
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Address Line | 5072 NIEMANVILLE TRL
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City | LITCHFIELD
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State | IL
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Zip | 62056-4613
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Country | US
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Telephone | 217-710-5522
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 183500000X
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Taxonomy Name | Pharmacist
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License Number | 051.299495
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License Number State | IL
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