Healthcare Provider Details

I. General information

NPI: 1053911636
Provider Name (Legal Business Name): BELTUS SIMO RPH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/31/2020
Last Update Date: 10/31/2020
Certification Date: 10/31/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3300 CRAIN HWY
BOWIE MD
20716-1398
US

IV. Provider business mailing address

8607 CROOKED TREE LN
LAUREL MD
20724-2478
US

V. Phone/Fax

Practice location:
  • Phone: 301-805-8853
  • Fax:
Mailing address:
  • Phone: 240-476-2356
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1835P2201X
TaxonomyAmbulatory Care Pharmacist
License Number18132
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number18132
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: