MEDICARE: LUIS ANGEL BERGOLLA 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	PS41487	FL

General Provider Information

NPI Number	:	1356426217
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LUIS ANGEL BERGOLLA PHARM. D.

Provider Business Mailing Address
First Line	:	14117 SW 51ST CT
Second Line	:
City	:	MIRAMAR
State	:	FL
Zip	:	33027-5971
Country	:	US
Telephone Number	:	305-816-5854
Fax Number	:

Provider Business Practice Location Address
First Line	:	5850 NW 183RD ST
Second Line	:
City	:	HIALEAH
State	:	FL
Zip	:	33015-6023
Country	:	US
Telephone Number	:	305-819-0705
Fax Number	:	305-819-0174

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

Provider Enumeration Date	:	10/26/2006
Last Update Date	:	07/08/2007

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