| NPI | 1912248345 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | DANIELLA HOUSTON Credentialing 305-628-6117 |
| Organization Subpart ? | No |
| Primary Taxonomy | 174400000X Specialist (Licence: GA 069385) |
| Additional Taxonomies | 332900000X Non-Pharmacy Dispensing Site (Licence: GA 069385) |
| Enumeration Date | 2013-03-11 |
| Last Update Date | 2024-07-19 |