| NPI | 1104256965 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 183500000X Pharmacist (Licence: OH 03116036) |
| Additional Taxonomies | 183500000X Pharmacist (Licence: MN 114161) |
| Enumeration Date | 2013-11-14 |
| Last Update Date | 2013-11-14 |