Provider Demographics
NPI:1174830970
Name:BERRY, LAUREL LACEY (RPH)
Entity Type:Individual
Prefix:MRS
First Name:LAUREL
Middle Name:LACEY
Last Name:BERRY
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14 INDUSTRIAL LN
Mailing Address - Street 2:
Mailing Address - City:SYLVANIA
Mailing Address - State:AL
Mailing Address - Zip Code:35988-2273
Mailing Address - Country:US
Mailing Address - Phone:256-638-6070
Mailing Address - Fax:
Practice Address - Street 1:14 INDUSTRIAL LN
Practice Address - Street 2:
Practice Address - City:SYLVANIA
Practice Address - State:AL
Practice Address - Zip Code:35988-2273
Practice Address - Country:US
Practice Address - Phone:256-638-6070
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-01
Last Update Date:2010-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL13916183500000X
TN9754183500000X
GA20116183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist