Provider Demographics
NPI:1003119371
Name:BERDINE, KENNETH B (RPH)
Entity Type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:B
Last Name:BERDINE
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 1:5717 MACCORKLE AVE SE
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25304-2803
Mailing Address - Country:US
Mailing Address - Phone:304-925-8400
Mailing Address - Fax:304-925-8433
Practice Address - Street 1:5717 MACCORKLE AVE SE
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25304-2803
Practice Address - Country:US
Practice Address - Phone:304-925-8400
Practice Address - Fax:304-925-8433
Is Sole Proprietor?:No
Enumeration Date:2010-12-08
Last Update Date:2010-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV4568183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist