Provider Demographics
NPI:1285351031
Name:HA, BETHUNE
Entity type:Individual
Prefix:
First Name:BETHUNE
Middle Name:
Last Name:HA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25016 GRATIOT AVE
Mailing Address - Street 2:
Mailing Address - City:EASTPOINTE
Mailing Address - State:MI
Mailing Address - Zip Code:48021-3319
Mailing Address - Country:US
Mailing Address - Phone:586-498-8426
Mailing Address - Fax:
Practice Address - Street 1:25016 GRATIOT AVE
Practice Address - Street 2:
Practice Address - City:EASTPOINTE
Practice Address - State:MI
Practice Address - Zip Code:48021-3319
Practice Address - Country:US
Practice Address - Phone:586-498-8426
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-24
Last Update Date:2022-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302411974183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist