Provider Demographics
NPI:1417360678
Name:THIBAULT, BETH
Entity Type:Individual
Prefix:
First Name:BETH
Middle Name:
Last Name:THIBAULT
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 1:585 HIGH ST
Mailing Address - Street 2:
Mailing Address - City:DEDHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02026-1858
Mailing Address - Country:US
Mailing Address - Phone:781-326-0061
Mailing Address - Fax:781-326-1430
Practice Address - Street 1:585 HIGH ST
Practice Address - Street 2:
Practice Address - City:DEDHAM
Practice Address - State:MA
Practice Address - Zip Code:02026-1858
Practice Address - Country:US
Practice Address - Phone:781-326-0061
Practice Address - Fax:781-326-1430
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-05
Last Update Date:2014-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPH21809183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist