=====================================================
General NPI Number Information
=====================================================
NPI Number | 1598302119
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BEACON HEALTH CARE SOLUTIONS INCORPORATED
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/02/2019
-----------------------------------------------------
Last Update Date | 10/13/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2790 BROADWAY AVE
-----------------------------------------------------
City | NORTH BEND
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97459-2216
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 541-808-0168
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2790 BROADWAY AVE
-----------------------------------------------------
City | NORTH BEND
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97459-2216
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 541-808-0168
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT AND CEO
-----------------------------------------------------
Name | DR. ANDREW THOMAS HIBBARD
-----------------------------------------------------
Credential | PHARM.D
-----------------------------------------------------
Telephone | 269-599-0857
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 291U00000X
-----------------------------------------------------
Taxonomy Name | Clinical Medical Laboratory
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 3336C0002X
-----------------------------------------------------
Taxonomy Name | Clinic Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 3336C0004X
-----------------------------------------------------
Taxonomy Name | Compounding Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #5
-----------------------------------------------------
Taxonomy Code | 333600000X
-----------------------------------------------------
Taxonomy Name | Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------