Provider Demographics
NPI:1770867897
Name:REID, BEAU (PHARM D)
Entity Type:Individual
Prefix:
First Name:BEAU
Middle Name:
Last Name:REID
Suffix:
Gender:M
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1141 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:KIMBERLY
Mailing Address - State:ID
Mailing Address - Zip Code:83341-5008
Mailing Address - Country:US
Mailing Address - Phone:208-705-4731
Mailing Address - Fax:
Practice Address - Street 1:1913 ADDISON AVE E
Practice Address - Street 2:
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301-5305
Practice Address - Country:US
Practice Address - Phone:208-734-4581
Practice Address - Fax:208-736-7144
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-07
Last Update Date:2021-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP6337183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist