Taxonomy Codes
The NPI record includes the healthcare provider taxonomy classification, state license number and state of licensure. The following information regarding the scope of practice of this provider is available:
| No. |
Taxonomy Code |
Taxonomy Clasification |
Taxonomy Specialization |
License Number |
License State |
Primary |
| 1 | 333600000X | Pharmacy | | | | No |
| 2 | 3336C0003X | Pharmacy | Community/Retail Pharmacy | | | No |
| 3 | 335E00000X | Prosthetic/Orthotic Supplier | | | | No |
| 4 | 332B00000X | Durable Medical Equipment & Medical Supplies | | | | Yes |
Other Identifiers
The following information regarding additional identifiers associated to this NPI record includes the other identifier number, identifier type, identifier state and issuer.
| No. |
Other Provider Identifier |
Other Provider Identifier Type |
Other Provider Identifier State |
Other Provider Identifier Issuer |
| 1 | 1002995 | OTHER | TEXAS | DURABLE MEDICAL EQUIPMENT LICENSE |
| 2 | 1265990113 | MEDICAID | MICHIGAN | |
| 3 | 20226000897 | OTHER | COLORADO | STATE OF COLORADO DEPARTMENT OF STATE |
| 4 | 69001755A | OTHER | INDIANA | INDIANA DURABLE MEDICAL EQUIPMENT LICENSE |
| 5 | 100103441 | MEDICAID | WISCONSIN | |
| 6 | 84774371 | MEDICAID | NEW MEXICO | |
| 7 | MG02104 | OTHER | ARKANSAS | ARKANSAS STATE BOARD OF PHARMACY |
| 8 | 291764716 | MEDICAID | ARKANSAS | |
| 9 | 0237000560 | OTHER | VIRGINIA | VIRGINIA DEPARTMENT OF HEALTH PROFESSIONS |
| 10 | 13157465-1714 | OTHER | UTAH | STATE OF UTAH DEPARTMENT OF COMMERCE |
| 11 | 18384 | OTHER | MISSISSIPPI | MISSISSIPPI BOARD OF PHARMACY |
| 12 | 500814948 | MEDICAID | OREGON | |
| 13 | CSW.0005155 | OTHER | CONNECTICUT | STATE OF CONNECTICUT DEPARTMENT OF CONSUMER PROTECTION |
| 14 | DME67480 | OTHER | IDAHO | IDAHO STATE BOARD OF PHARMACY |
| 15 | 07629 | OTHER | NEW HAMPSHIRE | STATE OF NEW HAMPSHIRE BOARD OF PHARMACY |
| 16 | 995007900 | MEDICAID | MARYLAND | |
| 17 | C002225 | OTHER | ARIZONA | ARIZONA STATE BOARD OF PHARMACY |
| 18 | 117826 | OTHER | CALIFORNIA | STATE OF CALIFORNIA DEPARTMENT OF PUBLIC HEALTH FOOD AND DRUG BRANCH |
| 19 | 16-119168 | OTHER | KANSAS | KANSAS STATE BOARD OF PHARMACY |
| 20 | 0426755 | MEDICAID | OHIO | |
| 21 | 281577 | OTHER | KENTUCKY | KENTUCKY BOARD OF DURABLE MEDICAL EQUIPMENT SUPPLIERS |
| 22 | DME.001297-NR | OTHER | LOUISIANA | LOUISIANA BOARD OF PHARMACY |
