Provider Demographics
NPI:1306314802
Name:BERGEVIN, ANNA
Entity type:Individual
Prefix:
First Name:ANNA
Middle Name:
Last Name:BERGEVIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10073 JANE DR
Mailing Address - Street 2:
Mailing Address - City:ALLENDALE
Mailing Address - State:MI
Mailing Address - Zip Code:49401-8055
Mailing Address - Country:US
Mailing Address - Phone:269-568-0925
Mailing Address - Fax:
Practice Address - Street 1:1212 E SHERMAN BLVD
Practice Address - Street 2:
Practice Address - City:MUSKEGON
Practice Address - State:MI
Practice Address - Zip Code:49444-1879
Practice Address - Country:US
Practice Address - Phone:231-672-2220
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-02
Last Update Date:2018-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI53020398891835P2201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P2201XPharmacy Service ProvidersPharmacistAmbulatory Care