Provider Demographics
NPI:1124752217
Name:BERGMAN, LAFAYE (PHARMD)
Entity type:Individual
Prefix:
First Name:LAFAYE
Middle Name:
Last Name:BERGMAN
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4526 S 5120 W
Mailing Address - Street 2:
Mailing Address - City:WEST VALLEY
Mailing Address - State:UT
Mailing Address - Zip Code:84120-5620
Mailing Address - Country:US
Mailing Address - Phone:801-969-5527
Mailing Address - Fax:
Practice Address - Street 1:4526 S 5120 W
Practice Address - Street 2:
Practice Address - City:WEST VALLEY
Practice Address - State:UT
Practice Address - Zip Code:84120-5620
Practice Address - Country:US
Practice Address - Phone:801-969-5527
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-13
Last Update Date:2022-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT37461917011835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist