Provider Demographics
NPI:1548301500
Name:BEVERLY, THOMAS E (RPH)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:E
Last Name:BEVERLY
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:175 S BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:COAL CITY
Mailing Address - State:IL
Mailing Address - Zip Code:60416-1532
Mailing Address - Country:US
Mailing Address - Phone:815-634-2391
Mailing Address - Fax:815-634-2729
Practice Address - Street 1:175 S BROADWAY ST
Practice Address - Street 2:
Practice Address - City:COAL CITY
Practice Address - State:IL
Practice Address - Zip Code:60416-1532
Practice Address - Country:US
Practice Address - Phone:815-634-2391
Practice Address - Fax:815-634-2729
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL363134286001Medicaid