Basic Information
Provider Information | |||||||||
NPI: | 1689769598 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BEAVER | ||||||||
FirstName: | DOUGLAS | ||||||||
MiddleName: | PAUL | ||||||||
NamePrefix: | MR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | PHARMD. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | HUG | ||||||||
OtherFirstName: | DOUGLAS | ||||||||
OtherMiddleName: | PAUL | ||||||||
OtherNamePrefix: | MR. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | PHARMD. | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | N6520 LUMBERJACK GUY RD | ||||||||
Address2: |   | ||||||||
City: | BLACK RIVER FALLS | ||||||||
State: | WI | ||||||||
PostalCode: | 546155405 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7152849851 | ||||||||
FaxNumber: | 7152842293 | ||||||||
Practice Location | |||||||||
Address1: | N6520 LUMBERJACK GUY RD | ||||||||
Address2: |   | ||||||||
City: | BLACK RIVER FALLS | ||||||||
State: | WI | ||||||||
PostalCode: | 546155405 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7152849851 | ||||||||
FaxNumber: | 7152842293 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/04/2006 | ||||||||
LastUpdateDate: | 04/19/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1835P1200X | 14094-40 | WI | Y |   | Pharmacy Service Providers | Pharmacist | Pharmacotherapy |
No ID Information.