Provider Demographics
NPI:1124135538
Name:BEAUMONT PHARMACY LLC
Entity type:Organization
Organization Name:BEAUMONT PHARMACY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TREY
Authorized Official - Middle Name:
Authorized Official - Last Name:HANEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:409-769-2406
Mailing Address - Street 1:3110 CALDER ST
Mailing Address - Street 2:
Mailing Address - City:BEAUMONT
Mailing Address - State:TX
Mailing Address - Zip Code:77702-1411
Mailing Address - Country:US
Mailing Address - Phone:409-866-1429
Mailing Address - Fax:409-866-3735
Practice Address - Street 1:3110 CALDER AVE.
Practice Address - Street 2:
Practice Address - City:BEAUMONT
Practice Address - State:TX
Practice Address - Zip Code:77702-1411
Practice Address - Country:US
Practice Address - Phone:409-866-1429
Practice Address - Fax:409-866-3735
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-23
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX25742OtherSTATE BOARD OF PHARMACY
TX149068Medicaid
TXFM0620004OtherDRUG ENFORCEMENT AGENCY