| NPI | 1962783159 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 183500000X Pharmacist (Licence: NY 055753) |
| Additional Taxonomies | 183500000X Pharmacist (Licence: VT 033.0077995) |
| Enumeration Date | 2011-09-01 |
| Last Update Date | 2011-09-01 |