Provider Demographics
NPI:1629315569
Name:BERBERETTE, MARVIN EDWARD
Entity Type:Individual
Prefix:
First Name:MARVIN
Middle Name:EDWARD
Last Name:BERBERETTE
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 1:9525 S SUNCOAST BLVD
Mailing Address - Street 2:
Mailing Address - City:HOMOSASSA
Mailing Address - State:FL
Mailing Address - Zip Code:34446-5034
Mailing Address - Country:US
Mailing Address - Phone:352-382-1155
Mailing Address - Fax:352-382-0983
Practice Address - Street 1:9525 S SUNCOAST BLVD
Practice Address - Street 2:
Practice Address - City:HOMOSASSA
Practice Address - State:FL
Practice Address - Zip Code:34446-5034
Practice Address - Country:US
Practice Address - Phone:352-382-1155
Practice Address - Fax:352-382-0983
Is Sole Proprietor?:No
Enumeration Date:2013-01-11
Last Update Date:2013-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS23381183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist