| NPI | 1386152338 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 183500000X Pharmacist (Licence: PA RP452546) |
| Additional Taxonomies | 171000000X Military Health Care Provider |
| Enumeration Date | 2018-01-11 |
| Last Update Date | 2018-11-07 |