1194003160 NPI number — DR. MATTHEW THOMAS BEAULAC PHARMD

Table of content: DR. MATTHEW THOMAS BEAULAC PHARMD (NPI 1194003160)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194003160 NPI number — DR. MATTHEW THOMAS BEAULAC PHARMD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BEAULAC
Provider First Name:
MATTHEW
Provider Middle Name:
THOMAS
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PHARMD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
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:
1194003160
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/25/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
53 ROURKE AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SOUTHINGTON
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06489-3015
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
207-590-1306
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1450 CHAPEL ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NEW HAVEN
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06511-4405
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
203-789-3493
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/25/2011

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 183500000X , with the licence number:  PCT.0012056 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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