Provider Demographics
NPI:1902281959
Name:BERG, CARMEN JOY (RPH)
Entity type:Individual
Prefix:MS
First Name:CARMEN
Middle Name:JOY
Last Name:BERG
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:CARMEN
Other - Middle Name:JOY
Other - Last Name:EDWARDS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RPH
Mailing Address - Street 1:PO BOX 200
Mailing Address - Street 2:
Mailing Address - City:MEDICAL LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:99022-0200
Mailing Address - Country:US
Mailing Address - Phone:509-299-1948
Mailing Address - Fax:509-299-1967
Practice Address - Street 1:2320 SOUTH SALNAVE ROAD
Practice Address - Street 2:
Practice Address - City:MEDICAL LAKE
Practice Address - State:WA
Practice Address - Zip Code:99022
Practice Address - Country:US
Practice Address - Phone:509-299-1948
Practice Address - Fax:509-299-1967
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-20
Last Update Date:2017-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA117061835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist