Provider Demographics
NPI:1063846327
Name:DEBERRY, MARY CHARLES (PHARMD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:CHARLES
Last Name:DEBERRY
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 1:11600 W 2ND PL STE 1817
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:CO
Mailing Address - Zip Code:80228-1527
Mailing Address - Country:US
Mailing Address - Phone:720-321-8290
Mailing Address - Fax:720-321-8291
Practice Address - Street 1:11600 W 2ND PL STE 1817
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:CO
Practice Address - Zip Code:80228-1527
Practice Address - Country:US
Practice Address - Phone:720-321-8290
Practice Address - Fax:720-321-8291
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-22
Last Update Date:2019-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA026942183500000X
CO19428183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist