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General NPI Number Information
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NPI Number | 1932117686
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Entity Type | Individual
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Provider Name | MR. BRADLEY GLENN MCBETH
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Gender | Male
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Dates
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Enumeration Date | 08/04/2006
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 411 DR. MARTIN LUTHER KING JR. DRIVE
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City | PEORIA
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State | IL
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Zip | 61605-2400
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Country | US
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Telephone | 309-497-0790
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Fax | 309-497-3567
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Provider Business Mailing Address
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Address Line | 706 W DEARBORN ST
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City | ELMWOOD
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State | IL
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Zip | 61529-9407
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Country | US
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Telephone | 309-742-8197
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 183500000X
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Taxonomy Name | Pharmacist
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License Number | 0051039895
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License Number State | IL
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