=====================================================
General NPI Number Information
=====================================================
NPI Number | 1295357150
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BRYAN BERGQUIST PHARMD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/14/2020
-----------------------------------------------------
Last Update Date | 05/14/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 603 N MONTANA AVE
-----------------------------------------------------
City | HELENA
-----------------------------------------------------
State | MT
-----------------------------------------------------
Zip | 59601-3885
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 406-442-9800
-----------------------------------------------------
Fax | 406-443-5889
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3 HIDDEN COVE CT
-----------------------------------------------------
City | HELENA
-----------------------------------------------------
State | MT
-----------------------------------------------------
Zip | 59601-5782
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 206-650-2932
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 11918
-----------------------------------------------------
License Number State | MT
-----------------------------------------------------