Provider Demographics
NPI:1356639496
Name:BERLY, LYDSIA M
Entity Type:Individual
Prefix:DR
First Name:LYDSIA
Middle Name:M
Last Name:BERLY
Suffix:
Gender:F
Credentials:
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 1702
Mailing Address - Street 2:
Mailing Address - City:COAMO
Mailing Address - State:PR
Mailing Address - Zip Code:00769-1702
Mailing Address - Country:US
Mailing Address - Phone:787-825-6520
Mailing Address - Fax:787-825-0116
Practice Address - Street 1:BALDORIOTY ST. 150
Practice Address - Street 2:
Practice Address - City:COAMO
Practice Address - State:PR
Practice Address - Zip Code:00769
Practice Address - Country:US
Practice Address - Phone:787-825-6520
Practice Address - Fax:787-825-0116
Is Sole Proprietor?:No
Enumeration Date:2011-07-11
Last Update Date:2011-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR4172183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist