Provider Demographics
NPI:1730525031
Name:BERGEN, SCOTT
Entity type:Individual
Prefix:MR
First Name:SCOTT
Middle Name:
Last Name:BERGEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:350 N HARRISON RD
Mailing Address - Street 2:APT 4201
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85748-3235
Mailing Address - Country:US
Mailing Address - Phone:520-305-4986
Mailing Address - Fax:
Practice Address - Street 1:350 N HARRISON RD
Practice Address - Street 2:APT 4201
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85748-3235
Practice Address - Country:US
Practice Address - Phone:520-305-4986
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-05-14
Last Update Date:2013-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZS016385183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist