| NPI | 1881033736 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 183500000X Pharmacist (Licence: WA 60786946) |
| Additional Taxonomies | 261QF0400X Clinic/Center, Federally Qualified Health Center (FQHC) (Licence: OR PI-0011446) |
| Enumeration Date | 2013-06-24 |
| Last Update Date | 2018-11-27 |