1174027114 NPI number — BFG KENNEWICK MASTER TENANT, LLC

Table of content: DR. KELLEY MARIE BEAKLEY PHARM.D. (NPI 1427333491)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174027114 NPI number — BFG KENNEWICK MASTER TENANT, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BFG KENNEWICK MASTER TENANT, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1174027114
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/23/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
228 N PARK AVE STE A
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WINTER PARK
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32789-3886
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
407-644-6444
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
575 N YOUNG ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KENNEWICK
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
99336-7806
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-491-3945
Provider Business Practice Location Address Fax Number:
509-491-3948
Provider Enumeration Date:
03/23/2018

Additional Information

Authorized Official

Authorized Official Last Name:
BOURNE
Authorized Official First Name:
ROBERT
Authorized Official Middle Name:
A
Authorized Official Title or Position:
INDIRECT MANAGER
Authorized Official Telephone Number:
407-644-6444

Provider Taxonomy Codes

  • Taxonomy code: 310400000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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