Provider Demographics
NPI:1982757399
Name:DIAB, BEAU S (RPH FACVP)
Entity Type:Individual
Prefix:
First Name:BEAU
Middle Name:S
Last Name:DIAB
Suffix:
Gender:M
Credentials:RPH FACVP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:426 N MILWAUKEE AVE
Mailing Address - Street 2:
Mailing Address - City:LIBERTYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60048-2248
Mailing Address - Country:US
Mailing Address - Phone:847-362-2005
Mailing Address - Fax:847-362-1304
Practice Address - Street 1:426 N MILWAUKEE AVE
Practice Address - Street 2:
Practice Address - City:LIBERTYVILLE
Practice Address - State:IL
Practice Address - Zip Code:60048-2248
Practice Address - Country:US
Practice Address - Phone:847-362-2005
Practice Address - Fax:847-362-1304
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist