Provider Demographics
NPI:1578149548
Name:BERRIAN, KELLEY (PHARMD)
Entity Type:Individual
Prefix:
First Name:KELLEY
Middle Name:
Last Name:BERRIAN
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1752 SW FINCH LN
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34953-1567
Mailing Address - Country:US
Mailing Address - Phone:229-561-4330
Mailing Address - Fax:
Practice Address - Street 1:902 SW ST LUCIE BLVD
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34986-1766
Practice Address - Country:US
Practice Address - Phone:772-446-8783
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-22
Last Update Date:2021-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS62036183500000X
GARPH032356183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist