Provider Demographics
NPI:1508223645
Name:BERKELEY HOME PHARMACY LLC
Entity Type:Organization
Organization Name:BERKELEY HOME PHARMACY LLC
Other - Org Name:BERKELEY HOME PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:TED
Authorized Official - Middle Name:TRISTAN
Authorized Official - Last Name:NUSSBAUM
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:843-899-4700
Mailing Address - Street 1:1404 BRITISH DR
Mailing Address - Street 2:
Mailing Address - City:MONCKS CORNER
Mailing Address - State:SC
Mailing Address - Zip Code:29461-7128
Mailing Address - Country:US
Mailing Address - Phone:843-899-4700
Mailing Address - Fax:843-899-4702
Practice Address - Street 1:1008 OLD HIGHWAY 52 STE G
Practice Address - Street 2:
Practice Address - City:MONCKS CORNER
Practice Address - State:SC
Practice Address - Zip Code:29461-3011
Practice Address - Country:US
Practice Address - Phone:843-899-4700
Practice Address - Fax:843-899-4702
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-01-20
Last Update Date:2021-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
SC163543336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2157670OtherPK
SC716354Medicaid