Provider Demographics
NPI:1851456248
Name:BERRY, PHYLLIS ANNE
Entity Type:Individual
Prefix:MR
First Name:PHYLLIS
Middle Name:ANNE
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 1:2112 WIGGINS ST
Mailing Address - Street 2:
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61822-3601
Mailing Address - Country:US
Mailing Address - Phone:217-356-4825
Mailing Address - Fax:217-359-7063
Practice Address - Street 1:1757 W KIRBY AVE
Practice Address - Street 2:
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61821-5500
Practice Address - Country:US
Practice Address - Phone:217-383-3398
Practice Address - Fax:217-359-7063
Is Sole Proprietor?:No
Enumeration Date:2006-12-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1835P1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P1200XPharmacy Service ProvidersPharmacistPharmacotherapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL371119538015Medicaid
IL371119538015Medicaid