Provider Demographics
NPI:1629661277
Name:BERRY, VICKI DALE
Entity Type:Individual
Prefix:
First Name:VICKI
Middle Name:DALE
Last Name:BERRY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:310 S 1ST ST
Mailing Address - Street 2:
Mailing Address - City:EUFAULA
Mailing Address - State:OK
Mailing Address - Zip Code:74432-3202
Mailing Address - Country:US
Mailing Address - Phone:877-774-3706
Mailing Address - Fax:855-529-8656
Practice Address - Street 1:310 S 1ST ST
Practice Address - Street 2:
Practice Address - City:EUFAULA
Practice Address - State:OK
Practice Address - Zip Code:74432-3202
Practice Address - Country:US
Practice Address - Phone:877-774-3706
Practice Address - Fax:855-529-8656
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-15
Last Update Date:2021-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK10640183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist