=====================================================
General NPI Number Information
=====================================================
NPI Number | 1043975238
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BEYANG KIMA-TABONG RPH
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/03/2021
-----------------------------------------------------
Last Update Date | 04/23/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 677 TIMPANY BLVD
-----------------------------------------------------
City | GARDNER
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 01440-3452
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 978-630-1352
-----------------------------------------------------
Fax | 978-632-2060
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 555 E MAIN ST
-----------------------------------------------------
City | ORANGE
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 01364-9515
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 978-544-5800
-----------------------------------------------------
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 | PH239558
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------