Provider Demographics
NPI:1043796162
Name:BEATTIE, BEAU ALAN (PHARMD)
Entity Type:Individual
Prefix:
First Name:BEAU
Middle Name:ALAN
Last Name:BEATTIE
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1636 S GLENSTONE AVE STE 108
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65804-1527
Mailing Address - Country:US
Mailing Address - Phone:417-450-4848
Mailing Address - Fax:
Practice Address - Street 1:1636 S GLENSTONE AVE STE 108
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65804-1527
Practice Address - Country:US
Practice Address - Phone:417-450-4848
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-11
Last Update Date:2018-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2018024628183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist