Provider Demographics
NPI:1548592439
Name:BERKLEY, STEPHEN ANTHONY (RPH)
Entity Type:Individual
Prefix:MR
First Name:STEPHEN
Middle Name:ANTHONY
Last Name:BERKLEY
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 1:10 BLACKSMITH DR
Mailing Address - Street 2:SUITE 2
Mailing Address - City:MALTA
Mailing Address - State:NY
Mailing Address - Zip Code:12020-4428
Mailing Address - Country:US
Mailing Address - Phone:518-899-8103
Mailing Address - Fax:518-899-2968
Practice Address - Street 1:10 BLACKSMITH DR
Practice Address - Street 2:SUITE 2
Practice Address - City:MALTA
Practice Address - State:NY
Practice Address - Zip Code:12020-4428
Practice Address - Country:US
Practice Address - Phone:518-899-8103
Practice Address - Fax:518-899-2968
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-03
Last Update Date:2010-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY046989183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY046989OtherPHARMACIST LICENSE - NYS EDUCATION DEPARTMENT