MEDICARE: THE BEAVERTON PHARMACY INC

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	333600000X	Pharmacy
2	3336C0003X	Community/Retail Pharmacy	5301005882	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	2042247	OTHER		PK

General Provider Information

NPI Number	:	1497844047
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THE BEAVERTON PHARMACY INC

Provider Business Mailing Address
First Line	:	PO BOX 575
Second Line	:
City	:	BEAVERTON
State	:	MI
Zip	:	48612-0575
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	127 W BROWN ST
Second Line	:
City	:	BEAVERTON
State	:	MI
Zip	:	48612-8119
Country	:	US
Telephone Number	:	989-435-7778
Fax Number	:	989-435-2581

Authorized Official
Title or Position	:	PHARMACIST PRESIDENT
Name	:	ROBERT RIFFERT
Credential	:
Telephone Number	:	989-435-7778

Provider Enumeration Date	:	10/12/2006
Last Update Date	:	07/20/2020

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Directions to “THE BEAVERTON PHARMACY INC ” Practice Location

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