Provider Demographics
NPI:1083043624
Name:BEACH, JODY SAMANTHA (PHARMD, CCP)
Entity Type:Individual
Prefix:MRS
First Name:JODY
Middle Name:SAMANTHA
Last Name:BEACH
Suffix:
Gender:F
Credentials:PHARMD, CCP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 TRILBY AVE
Mailing Address - Street 2:
Mailing Address - City:WESTVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:08093-1651
Mailing Address - Country:US
Mailing Address - Phone:856-229-3904
Mailing Address - Fax:
Practice Address - Street 1:11 TRILBY AVE
Practice Address - Street 2:
Practice Address - City:WESTVILLE
Practice Address - State:NJ
Practice Address - Zip Code:08093-1651
Practice Address - Country:US
Practice Address - Phone:856-229-3904
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-04
Last Update Date:2013-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARP443154183500000X
NJ28RI02898400183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist