Provider Demographics
NPI:1942874433
Name:BLACK, BETH MARIE (PHARMD)
Entity Type:Individual
Prefix:
First Name:BETH
Middle Name:MARIE
Last Name:BLACK
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 1:10 COLUMBIA AVE E
Mailing Address - Street 2:
Mailing Address - City:BATTLE CREEK
Mailing Address - State:MI
Mailing Address - Zip Code:49015-3704
Mailing Address - Country:US
Mailing Address - Phone:269-962-1965
Mailing Address - Fax:
Practice Address - Street 1:10 COLUMBIA AVE E
Practice Address - Street 2:
Practice Address - City:BATTLE CREEK
Practice Address - State:MI
Practice Address - Zip Code:49015-3704
Practice Address - Country:US
Practice Address - Phone:269-962-1965
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-18
Last Update Date:2021-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302046511183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist