Provider Demographics
NPI:1558954602
Name:BRE'S BEAUTIQUE RX
Entity Type:Organization
Organization Name:BRE'S BEAUTIQUE RX
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BREONNA
Authorized Official - Middle Name:
Authorized Official - Last Name:GIST
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:757-609-0334
Mailing Address - Street 1:112 FARO LN
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:VA
Mailing Address - Zip Code:23703-5475
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3590 TOWNE POINT RD UNIT 6543
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:VA
Practice Address - Zip Code:23703-1309
Practice Address - Country:US
Practice Address - Phone:757-609-0334
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-02-18
Last Update Date:2021-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier