Provider Demographics
NPI:1215418942
Name:KILLOUGH, BETH
Entity Type:Individual
Prefix:
First Name:BETH
Middle Name:
Last Name:KILLOUGH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 E ALICE ST
Mailing Address - Street 2:
Mailing Address - City:BAINBRIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:39819-4998
Mailing Address - Country:US
Mailing Address - Phone:229-246-9551
Mailing Address - Fax:
Practice Address - Street 1:500 E ALICE ST
Practice Address - Street 2:
Practice Address - City:BAINBRIDGE
Practice Address - State:GA
Practice Address - Zip Code:39819-4998
Practice Address - Country:US
Practice Address - Phone:229-246-9551
Practice Address - Fax:229-246-9574
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-21
Last Update Date:2018-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA012181183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist