Provider Demographics
NPI:1871683045
Name:BERRY PHARMACY AND WELLNESS SERVICES LLC
Entity Type:Organization
Organization Name:BERRY PHARMACY AND WELLNESS SERVICES LLC
Other - Org Name:WEST BEND PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:
Authorized Official - Last Name:BERRY
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:262-338-6444
Mailing Address - Street 1:PO BOX 553
Mailing Address - Street 2:
Mailing Address - City:WEST BEND
Mailing Address - State:WI
Mailing Address - Zip Code:53095-0553
Mailing Address - Country:US
Mailing Address - Phone:262-338-6444
Mailing Address - Fax:262-338-3635
Practice Address - Street 1:1709 S 18TH AVE
Practice Address - Street 2:
Practice Address - City:WEST BEND
Practice Address - State:WI
Practice Address - Zip Code:53095-7808
Practice Address - Country:US
Practice Address - Phone:262-338-6444
Practice Address - Fax:262-338-3635
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-16
Last Update Date:2010-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI8792423336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
5110515OtherNCPDP PROVIDER IDENTIFICATION NUMBER
WI36222100Medicaid
6082820001Medicare NSC