Provider Demographics
NPI:1821604646
Name:BETHEL BUSINESS LLC
Entity Type:Organization
Organization Name:BETHEL BUSINESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST/CO OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHANNON
Authorized Official - Middle Name:BELLE
Authorized Official - Last Name:BETHEL
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:719-634-5541
Mailing Address - Street 1:1640 S NEVADA AVE
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80905-2222
Mailing Address - Country:US
Mailing Address - Phone:719-634-5541
Mailing Address - Fax:
Practice Address - Street 1:1640 S NEVADA AVE
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80905-2222
Practice Address - Country:US
Practice Address - Phone:719-634-5541
Practice Address - Fax:719-634-0692
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BETHEL BUSINESS LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-09-17
Last Update Date:2020-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO64108066Medicaid