Provider Demographics
NPI:1609093293
Name:BERTHELOT, SHANE KELVIN (RPH)
Entity Type:Individual
Prefix:MR
First Name:SHANE
Middle Name:KELVIN
Last Name:BERTHELOT
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 1:3418 MAIN HWY
Mailing Address - Street 2:#11569 RITE AID
Mailing Address - City:BAMBERG
Mailing Address - State:SC
Mailing Address - Zip Code:29003-2135
Mailing Address - Country:US
Mailing Address - Phone:803-378-4500
Mailing Address - Fax:803-378-4500
Practice Address - Street 1:1010 S AIRPORT DR STE C
Practice Address - Street 2:
Practice Address - City:WESLACO
Practice Address - State:TX
Practice Address - Zip Code:78596-6600
Practice Address - Country:US
Practice Address - Phone:803-378-4500
Practice Address - Fax:803-378-4500
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-18
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC12062183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist