Provider Demographics
NPI:1487254884
Name:HORNBUCKLE, BETH MARIE
Entity type:Individual
Prefix:
First Name:BETH
Middle Name:MARIE
Last Name:HORNBUCKLE
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 1:1605 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MARYVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:64468-2611
Mailing Address - Country:US
Mailing Address - Phone:660-562-3593
Mailing Address - Fax:660-562-3282
Practice Address - Street 1:1605 S MAIN ST
Practice Address - Street 2:
Practice Address - City:MARYVILLE
Practice Address - State:MO
Practice Address - Zip Code:64468-2611
Practice Address - Country:US
Practice Address - Phone:660-562-3593
Practice Address - Fax:660-562-3282
Is Sole Proprietor?:No
Enumeration Date:2020-10-27
Last Update Date:2020-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2006025345183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist