Basic Information
| Provider Information | |||||||||
| NPI: | 1053911636 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SIMO | ||||||||
| FirstName: | BELTUS | ||||||||
| MiddleName: | |||||||||
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| Credential: | RPH | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8607 CROOKED TREE LN | ||||||||
| Address2: | |||||||||
| City: | LAUREL | ||||||||
| State: | MD | ||||||||
| PostalCode: | 207242478 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2404762356 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3300 CRAIN HWY | ||||||||
| Address2: | |||||||||
| City: | BOWIE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 207161398 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3018058853 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/31/2020 | ||||||||
| LastUpdateDate: | 10/31/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 10/31/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1835P2201X | 18132 | MD | N | 183500000X | 18132 | MD | Y | Pharmacy Service Providers | Pharmacist |
No ID Information.