| NPI | 1760104434 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 3336M0002X Pharmacy, Mail Order Pharmacy |
| Additional Taxonomies | 171W00000X Contractor |
| 332900000X Non-Pharmacy Dispensing Site | |
| 332B00000X Durable Medical Equipment & Medical Supplies | |
| 333600000X Pharmacy | |
| Enumeration Date | 2022-09-19 |
| Last Update Date | 2022-11-21 |