Provider Demographics
NPI:1619145299
Name:BERGQUIST, RICK ROGER (RPH)
Entity type:Individual
Prefix:
First Name:RICK
Middle Name:ROGER
Last Name:BERGQUIST
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1500 BROOKS AVE
Mailing Address - Street 2:ATTN: PHARMACY MANAGER
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14624-3512
Mailing Address - Country:US
Mailing Address - Phone:585-239-2020
Mailing Address - Fax:585-239-2015
Practice Address - Street 1:1000 HIGHWAY 36 NORTH
Practice Address - Street 2:ATTN: PHARMACY MANAGER
Practice Address - City:HORNELL
Practice Address - State:NY
Practice Address - Zip Code:14843
Practice Address - Country:US
Practice Address - Phone:607-324-4870
Practice Address - Fax:607-324-3313
Is Sole Proprietor?:No
Enumeration Date:2008-02-15
Last Update Date:2008-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY035985183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY035985OtherPHARMACIST LICENSE