Provider Demographics
NPI:1073114534
Name:BERSU, ANDREW DIMITRI
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:DIMITRI
Last Name:BERSU
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 1:1505 COUNTY ROAD 220
Mailing Address - Street 2:
Mailing Address - City:FLEMING ISLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32003-7926
Mailing Address - Country:US
Mailing Address - Phone:904-278-5988
Mailing Address - Fax:904-278-3627
Practice Address - Street 1:1505 COUNTY ROAD 220
Practice Address - Street 2:
Practice Address - City:FLEMING ISLAND
Practice Address - State:FL
Practice Address - Zip Code:32003-7926
Practice Address - Country:US
Practice Address - Phone:904-278-5988
Practice Address - Fax:904-278-3627
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-02
Last Update Date:2020-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS28421183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist