=====================================================
General NPI Number Information
=====================================================
NPI Number | 1043796162
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BEAU ALAN BEATTIE PHARMD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/11/2018
-----------------------------------------------------
Last Update Date | 09/19/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1636 S GLENSTONE AVE STE 108
-----------------------------------------------------
City | SPRINGFIELD
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 65804-1527
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 417-450-4848
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1636 S GLENSTONE AVE STE 108
-----------------------------------------------------
City | SPRINGFIELD
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 65804-1527
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 417-450-4848
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 2018024628
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------