Provider Demographics
NPI:1407252745
Name:BEAM AND BLIZZARD, LLC
Entity Type:Organization
Organization Name:BEAM AND BLIZZARD, LLC
Other - Org Name:INDIAN TRAIL PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACY MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TERRY
Authorized Official - Middle Name:A
Authorized Official - Last Name:DEVINE
Authorized Official - Suffix:JR
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:704-821-7617
Mailing Address - Street 1:106 INDIAN TRAIL RD S
Mailing Address - Street 2:
Mailing Address - City:INDIAN TRAIL
Mailing Address - State:NC
Mailing Address - Zip Code:28079-9669
Mailing Address - Country:US
Mailing Address - Phone:704-821-7617
Mailing Address - Fax:704-821-0177
Practice Address - Street 1:106 INDIAN TRAIL RD S
Practice Address - Street 2:
Practice Address - City:INDIAN TRAIL
Practice Address - State:NC
Practice Address - Zip Code:28079-9669
Practice Address - Country:US
Practice Address - Phone:704-821-7617
Practice Address - Fax:704-821-0177
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-11-14
Last Update Date:2014-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC11558333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0905117Medicaid
NC6973150001OtherMEDICARE PTAN