Basic Information
| Provider Information | |||||||||
| NPI: | 1215418942 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KILLOUGH | ||||||||
| FirstName: | BETH | ||||||||
| MiddleName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 500 E ALICE ST | ||||||||
| Address2: | |||||||||
| City: | BAINBRIDGE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 398194998 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2292469551 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 500 E ALICE ST | ||||||||
| Address2: | |||||||||
| City: | BAINBRIDGE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 398194998 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2292469551 | ||||||||
| FaxNumber: | 2292469574 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/21/2018 | ||||||||
| LastUpdateDate: | 08/21/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183500000X | 012181 | GA | Y | Pharmacy Service Providers | Pharmacist |
No ID Information.