Healthcare Provider Details

I. General information

NPI: 1740374974
Provider Name (Legal Business Name): BEAM AND BLIZZARD LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/03/2006
Last Update Date: 11/10/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

106 INDIAN TRAIL RD S
INDIAN TRAIL NC
28079-9669
US

IV. Provider business mailing address

106 INDIAN TRAIL RD S
INDIAN TRAIL NC
28079-9669
US

V. Phone/Fax

Practice location:
  • Phone: 704-821-7617
  • Fax: 704-821-0177
Mailing address:
  • Phone: 704-821-7617
  • Fax: 704-821-0177

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number11558
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: TERRY DEVINE
Title or Position: MANAGER
Credential:
Phone: 704-821-7617