Provider Demographics
NPI:1376642439
Name:BERGOICH, ANDREA ELLEN (CPHT)
Entity type:Individual
Prefix:MISS
First Name:ANDREA
Middle Name:ELLEN
Last Name:BERGOICH
Suffix:
Gender:F
Credentials:CPHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12402 SAFESHELTER DR S
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32225-1783
Mailing Address - Country:US
Mailing Address - Phone:904-535-3480
Mailing Address - Fax:
Practice Address - Street 1:12402 SAFESHELTER DR S
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32225-1783
Practice Address - Country:US
Practice Address - Phone:904-535-3480
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL250101030358003183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician