Provider Demographics
NPI:1114278926
Name:BEACON PROFESSIONAL PHARMACY, INC
Entity Type:Organization
Organization Name:BEACON PROFESSIONAL PHARMACY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:RENE
Authorized Official - Middle Name:A
Authorized Official - Last Name:EID
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:586-909-4964
Mailing Address - Street 1:54876 ALEXIS CT
Mailing Address - Street 2:
Mailing Address - City:SHELBY TWP
Mailing Address - State:MI
Mailing Address - Zip Code:48316-1359
Mailing Address - Country:US
Mailing Address - Phone:586-909-4964
Mailing Address - Fax:
Practice Address - Street 1:23350 GREENFIELD RD
Practice Address - Street 2:
Practice Address - City:OAK PARK
Practice Address - State:MI
Practice Address - Zip Code:48237-2496
Practice Address - Country:US
Practice Address - Phone:248-968-3800
Practice Address - Fax:248-968-3801
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-20
Last Update Date:2013-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy