| NPI | 1235112095 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 183500000X Pharmacist (Licence: WA PH60562356) |
| Additional Taxonomies | 183700000X Pharmacy Technician (Licence: WA VA00061470) |
| Enumeration Date | 2005-11-25 |
| Last Update Date | 2015-11-05 |