MEDICARE: MARY BERGSTROM PHARM D

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	5302030388	MI
2	183500000X	Pharmacist	26020791A	IN

General Provider Information

NPI Number	:	1285234211
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARY BERGSTROM PHARM D

Provider Business Mailing Address
First Line	:	6736 LIMA RD
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46818-1118
Country	:	US
Telephone Number	:	260-490-0638
Fax Number	:

Provider Business Practice Location Address
First Line	:	6736 LIMA RD
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46818-1118
Country	:	US
Telephone Number	:	260-490-0638
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/28/2020
Last Update Date	:	10/28/2020

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Directions to “ MARY BERGSTROM PHARM D” Practice Location

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