| NPI | 1255485355 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 183500000X Pharmacist (Licence: SD 4214) |
| Additional Taxonomies | 332800000X Indian Health Service/Tribal/Urban Indian Health (I/T/U) Pharmacy (Licence: WA CF00003827) |
| Enumeration Date | 2007-01-23 |
| Last Update Date | 2007-07-08 |