Provider Demographics
NPI:1255485355
Name:BERG, THOMAS RICHARD (RPH)
Entity Type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:RICHARD
Last Name:BERG
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:PO BOX 290
Mailing Address - Street 2:
Mailing Address - City:INCHELIUM
Mailing Address - State:WA
Mailing Address - Zip Code:99138-0290
Mailing Address - Country:US
Mailing Address - Phone:509-722-7009
Mailing Address - Fax:509-722-7021
Practice Address - Street 1:39 SHORTCUT ROAD
Practice Address - Street 2:
Practice Address - City:INCHELIUM
Practice Address - State:WA
Practice Address - Zip Code:99138-0290
Practice Address - Country:US
Practice Address - Phone:509-722-7009
Practice Address - Fax:509-722-7021
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD4214183500000X
WACF00003827332800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered183500000XPharmacy Service ProvidersPharmacist
Not Answered332800000XSuppliersIndian Health Service/Tribal/Urban Indian Health (I/T/U) Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA4924735OtherNABP
WACF00003827OtherPHARMACY LICENSE
WA6008767Medicaid