Provider Demographics
NPI:1053564286
Name:MAES, BETH MARIE (PHARMD)
Entity type:Individual
Prefix:DR
First Name:BETH
Middle Name:MARIE
Last Name:MAES
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:DR
Other - First Name:BETH
Other - Middle Name:MARIE
Other - Last Name:PROCHAZKA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHARMD
Mailing Address - Street 1:3708 TEEPLE AVE
Mailing Address - Street 2:
Mailing Address - City:FORT GRATIOT
Mailing Address - State:MI
Mailing Address - Zip Code:48059-4182
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2601 ELECTRIC AVE
Practice Address - Street 2:
Practice Address - City:PORT HURON
Practice Address - State:MI
Practice Address - Zip Code:48060-6587
Practice Address - Country:US
Practice Address - Phone:810-985-1480
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-10-31
Last Update Date:2011-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302035440183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist