=====================================================
General NPI Number Information
=====================================================
NPI Number | 1770867897
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BEAU REID PHARM D
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/07/2011
-----------------------------------------------------
Last Update Date | 01/25/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1913 ADDISON AVE E
-----------------------------------------------------
City | TWIN FALLS
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83301-5305
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-734-4581
-----------------------------------------------------
Fax | 208-736-7144
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1141 PARK AVE
-----------------------------------------------------
City | KIMBERLY
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83341-5008
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-705-4731
-----------------------------------------------------
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 | P6337
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------