Provider Demographics
NPI:1063664175
Name:BEATTIE, LYAL STORM (RPH)
Entity Type:Individual
Prefix:MR
First Name:LYAL
Middle Name:STORM
Last Name:BEATTIE
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1295 E BRIDGE ST
Mailing Address - Street 2:SUITE 103
Mailing Address - City:BRIGHTON
Mailing Address - State:CO
Mailing Address - Zip Code:80601-2277
Mailing Address - Country:US
Mailing Address - Phone:303-655-1500
Mailing Address - Fax:303-655-1502
Practice Address - Street 1:1295 E BRIDGE ST
Practice Address - Street 2:SUITE 103
Practice Address - City:BRIGHTON
Practice Address - State:CO
Practice Address - Zip Code:80601-2277
Practice Address - Country:US
Practice Address - Phone:303-655-1500
Practice Address - Fax:303-655-1502
Is Sole Proprietor?:No
Enumeration Date:2008-10-21
Last Update Date:2008-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO13516183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist