Provider Demographics
NPI:1295463164
Name:BERG, KASSANDRA (PHARMD)
Entity type:Individual
Prefix:
First Name:KASSANDRA
Middle Name:
Last Name:BERG
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 LITTLE TEXAS RD
Mailing Address - Street 2:
Mailing Address - City:TRAVELERS REST
Mailing Address - State:SC
Mailing Address - Zip Code:29690-9428
Mailing Address - Country:US
Mailing Address - Phone:864-834-4451
Mailing Address - Fax:
Practice Address - Street 1:100 LITTLE TEXAS RD
Practice Address - Street 2:
Practice Address - City:TRAVELERS REST
Practice Address - State:SC
Practice Address - Zip Code:29690-9428
Practice Address - Country:US
Practice Address - Phone:864-834-4451
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-09
Last Update Date:2023-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC43617183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC43617OtherBOARD OF PHARMACY