=====================================================
General NPI Number Information
=====================================================
NPI Number | 1619343225
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DONALD BEUSSINK
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/18/2015
-----------------------------------------------------
Last Update Date | 08/18/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 708 HIGH POINT DR
-----------------------------------------------------
City | LAKE SAINT LOUIS
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63367-2032
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-570-6856
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 708 HIGH POINT DR
-----------------------------------------------------
City | LAKE SAINT LOUIS
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63367-2032
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-570-6856
-----------------------------------------------------
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 | 040401
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------