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General NPI Number Information
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NPI Number | 1609093293
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Entity Type | Individual
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Provider Name | SHANE KELVIN BERTHELOT RPH
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Gender | Male
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Dates
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Enumeration Date | 04/18/2007
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Last Update Date | 07/21/2022
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Provider Practice Location Address
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Address Line | 1010 S AIRPORT DR STE C
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City | WESLACO
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State | TX
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Zip | 78596-6600
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Country | US
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Telephone | 803-378-4500
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Fax | 803-378-4500
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Provider Business Mailing Address
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Address Line | 3418 MAIN HWY #11569 RITE AID
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City | BAMBERG
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State | SC
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Zip | 29003-2135
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Country | US
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Telephone | 803-378-4500
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Fax | 803-378-4500
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 183500000X
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Taxonomy Name | Pharmacist
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License Number | 12062
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License Number State | SC
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