Provider Demographics
NPI:1528690989
Name:BERRY, TARA (PHARMD)
Entity type:Individual
Prefix:
First Name:TARA
Middle Name:
Last Name:BERRY
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 1:331 HAMPSHIRE CT
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48124-1125
Mailing Address - Country:US
Mailing Address - Phone:313-610-5865
Mailing Address - Fax:
Practice Address - Street 1:6245 INKSTER RD
Practice Address - Street 2:
Practice Address - City:GARDEN CITY
Practice Address - State:MI
Practice Address - Zip Code:48135-4001
Practice Address - Country:US
Practice Address - Phone:734-458-4224
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-04
Last Update Date:2020-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302411574183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist