| NPI | 1588132385 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: ND RL21253) |
| Additional Taxonomies | 333600000X Pharmacy (Licence: UT 9524794-1701) |
| 3336L0003X Pharmacy Long Term Care Pharmacy (Licence: ID P8135) | |
| Enumeration Date | 2018-11-09 |
| Last Update Date | 2024-07-29 |