Provider Demographics
NPI:1760856264
Name:BERRY, ALI A
Entity Type:Individual
Prefix:
First Name:ALI
Middle Name:A
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 1:27012 HAVELOCK DR
Mailing Address - Street 2:
Mailing Address - City:DEARBORN HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48127-3639
Mailing Address - Country:US
Mailing Address - Phone:313-283-3872
Mailing Address - Fax:
Practice Address - Street 1:27012 HAVELOCK DR
Practice Address - Street 2:
Practice Address - City:DEARBORN HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48127-3639
Practice Address - Country:US
Practice Address - Phone:313-283-3872
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-20
Last Update Date:2015-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302042520183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist