Provider Demographics
NPI:1538202098
Name:BERGHAUSER, MARY ELLEN (PHARMACIST)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:ELLEN
Last Name:BERGHAUSER
Suffix:
Gender:F
Credentials:PHARMACIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1575 LINKSIDE DR
Mailing Address - Street 2:
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32003-7767
Mailing Address - Country:US
Mailing Address - Phone:904-264-8543
Mailing Address - Fax:904-269-1283
Practice Address - Street 1:1339 BLANDING BLVD
Practice Address - Street 2:
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32065-8022
Practice Address - Country:US
Practice Address - Phone:904-272-2095
Practice Address - Fax:904-272-0310
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS31299183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPS31299OtherPHARMACY LICENSE