Provider Demographics
NPI:1558806364
Name:BEAULAC, KIRTHANA (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:KIRTHANA
Middle Name:
Last Name:BEAULAC
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:649 CAMBRIDGE TPKE
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:MA
Mailing Address - Zip Code:01742-3726
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:649 CAMBRIDGE TPKE
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:MA
Practice Address - Zip Code:01742-3726
Practice Address - Country:US
Practice Address - Phone:914-320-3255
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-03
Last Update Date:2017-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPH233161183500000X
CTPCT0011994183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist