Provider Demographics
NPI:1740239631
Name:BERRA, ANTHONY GERARD III (RPH)
Entity Type:Individual
Prefix:MR
First Name:ANTHONY
Middle Name:GERARD
Last Name:BERRA
Suffix:III
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 1:522 BAMBURY WAY
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63122-1143
Mailing Address - Country:US
Mailing Address - Phone:314-966-4519
Mailing Address - Fax:
Practice Address - Street 1:3023 N BALLAS RD
Practice Address - Street 2:SUITE 100 D
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63131-2330
Practice Address - Country:US
Practice Address - Phone:314-996-7501
Practice Address - Fax:314-996-7502
Is Sole Proprietor?:No
Enumeration Date:2006-05-08
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO041710183500000X
IL183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1019230001Medicare NSC