Provider Demographics
NPI:1255354015
Name:BEASLEY, EDMOND RAY (PHARMACIST)
Entity type:Individual
Prefix:
First Name:EDMOND
Middle Name:RAY
Last Name:BEASLEY
Suffix:
Gender:M
Credentials:PHARMACIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:382 N 400 W
Mailing Address - Street 2:
Mailing Address - City:AMERICAN FORK
Mailing Address - State:UT
Mailing Address - Zip Code:84003-1422
Mailing Address - Country:US
Mailing Address - Phone:801-756-3896
Mailing Address - Fax:
Practice Address - Street 1:76 N 1100 E
Practice Address - Street 2:
Practice Address - City:AMERICAN FORK
Practice Address - State:UT
Practice Address - Zip Code:84003-2952
Practice Address - Country:US
Practice Address - Phone:801-756-4021
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT135545-1701183500000X
UT135541-17011835P1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered183500000XPharmacy Service ProvidersPharmacist
Not Answered1835P1200XPharmacy Service ProvidersPharmacistPharmacotherapy