| NPI | 1619639275 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 3336C0003X Pharmacy Community/Retail Pharmacy |
| Additional Taxonomies | 3336C0004X Pharmacy Compounding Pharmacy |
| 3336L0003X Pharmacy Long Term Care Pharmacy | |
| 3336S0011X Pharmacy Specialty Pharmacy | |
| Enumeration Date | 2021-10-12 |
| Last Update Date | 2021-10-12 |