Provider Demographics
NPI:1619440708
Name:BERRY, STANLEY
Entity Type:Individual
Prefix:MR
First Name:STANLEY
Middle Name:
Last Name:BERRY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 W WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:HOLLANDALE
Mailing Address - State:MS
Mailing Address - Zip Code:38748-3846
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:100 W WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:HOLLANDALE
Practice Address - State:MS
Practice Address - Zip Code:38748-3846
Practice Address - Country:US
Practice Address - Phone:662-827-5561
Practice Address - Fax:662-827-5145
Is Sole Proprietor?:No
Enumeration Date:2019-01-10
Last Update Date:2019-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSE06479183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist