| NPI | 1841285830 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208000000X Pediatrics (Licence: FL ME64041) |
| Additional Taxonomies | 332900000X Non-Pharmacy Dispensing Site (Licence: FL 5719274) |
| Enumeration Date | 2005-09-15 |
| Last Update Date | 2014-06-17 |