| NPI | 1114200821 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 183500000X Pharmacist (Licence: VT 033.0003767) |
| Additional Taxonomies | 183500000X Pharmacist (Licence: NY 057607) |
| 183500000X Pharmacist (Licence: MA PH26780) | |
| 183500000X Pharmacist (Licence: CA 60940) | |
| Enumeration Date | 2011-09-20 |
| Last Update Date | 2012-11-16 |