Provider Demographics
NPI:1992000806
Name:BERRY, LINDA
Entity Type:Individual
Prefix:
First Name:LINDA
Middle Name:
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 1:6428 REA RD
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28277-2528
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6428 REA RD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28277-2528
Practice Address - Country:US
Practice Address - Phone:704-541-5713
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-01-24
Last Update Date:2011-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA11021183500000X
NC11558183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist