Provider Demographics
NPI:1932117686
Name:MCBETH, BRADLEY GLENN
Entity Type:Individual
Prefix:MR
First Name:BRADLEY
Middle Name:GLENN
Last Name:MCBETH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:706 W DEARBORN ST
Mailing Address - Street 2:
Mailing Address - City:ELMWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:61529-9407
Mailing Address - Country:US
Mailing Address - Phone:309-742-8197
Mailing Address - Fax:
Practice Address - Street 1:411 DR. MARTIN LUTHER KING JR. DRIVE
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61605-2400
Practice Address - Country:US
Practice Address - Phone:309-497-0790
Practice Address - Fax:309-497-3567
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0051039895183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist