| NPI | 1124534532 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 3336H0001X Pharmacy, Home Infusion Therapy Pharmacy (Licence: IA 16421) |
| Additional Taxonomies | 3336C0003X Pharmacy, Community/Retail Pharmacy (Licence: IA 16421) |
| 3336S0011X Pharmacy, Specialty Pharmacy (Licence: IA 16421) | |
| Enumeration Date | 2017-12-20 |
| Last Update Date | 2017-12-20 |