Healthcare Provider Details

I. General information

NPI: 1255485355
Provider Name (Legal Business Name): THOMAS RICHARD BERG R.PH.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/23/2007
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

39 SHORTCUT ROAD
INCHELIUM WA
99138-0290
US

IV. Provider business mailing address

PO BOX 290
INCHELIUM WA
99138-0290
US

V. Phone/Fax

Practice location:
  • Phone: 509-722-7009
  • Fax: 509-722-7021
Mailing address:
  • Phone: 509-722-7009
  • Fax: 509-722-7021

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number4214
License Number StateSD
# 2
Primary TaxonomyY
Taxonomy Code332800000X
TaxonomyIndian Health Service/Tribal/Urban Indian Health (I/T/U) Pharmacy
License NumberCF00003827
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: