MEDICARE: BETH PENSE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	051.289115	IL

General Provider Information

NPI Number	:	1457635153
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BETH PENSE

Provider Business Mailing Address
First Line	:	2631 CASCADE LAKE DR
Second Line	:
City	:	BELLEVILLE
State	:	IL
Zip	:	62221-8621
Country	:	US
Telephone Number	:	618-239-6617
Fax Number	:	618-239-6625

Provider Business Practice Location Address
First Line	:	1108 HARTMAN LN
Second Line	:
City	:	BELLEVILLE
State	:	IL
Zip	:	62221-7921
Country	:	US
Telephone Number	:	618-239-6617
Fax Number	:	618-239-6625

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/29/2011
Last Update Date	:	09/29/2011

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Directions to “ BETH PENSE ” Practice Location

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