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 | 3336M0002X | Pharmacy | Mail Order Pharmacy | | | No |
| 4 | 332B00000X | Durable Medical Equipment & Medical Supplies | | | | No |
| 5 | 3336S0011X | Pharmacy | Specialty Pharmacy | | | 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 | 12766690-1708 | OTHER | UTAH | PHARMACY LICENSE |
| 2 | PCN.0003825 | OTHER | CONNECTICUT | PHARMACY LICENSE |
| 3 | 008107334 | MEDICAID | CONNECTICUT | |
| 4 | 0391994 | MEDICAID | OHIO | |
| 5 | 300033160 | MEDICAID | INDIANA | |
| 6 | 193819 | OTHER | ALASKA | PHARMACY LICENSE |
| 7 | 14929 | OTHER | NORTH CAROLINA | PHARMACY LICENSE |
| 8 | OSP.0007488 | OTHER | COLORADO | PHARMACY LICENSE |
| 9 | PO8489 | OTHER | MARYLAND | PHARMACY LICENSE |
| 10 | 202190019 | MEDICAID | IDAHO | |
| 11 | 054.021498 | OTHER | ILLINOIS | PHARMACY LICENSE |
| 12 | 5301012447 | OTHER | MICHIGAN | PHARMACY LICENSE |
| 13 | IN2605 | OTHER | KENTUCKY | PHARMACY LICENSE |
| 14 | NR5450 | OTHER | IOWA | PHARMACY LICENSE |
| 15 | VS0172399 | MEDICAID | MICHIGAN | |
| 16 | 0214002479 | OTHER | VIRGINIA | PHARMACY LICENSE |
| 17 | 0240000154 | OTHER | OHIO | PHARMACY LICENSE |
| 18 | 036.0134601 | OTHER | VERMONT | PHARMACY LICENSE |
| 19 | 400-2266 | OTHER | SOUTH DAKOTA | PHARMACY LICENSE |
| 20 | A9-0012676 | OTHER | DELAWARE | PHARMACY LICENSE |
| 21 | MO0561538 | OTHER | WEST VIRGINIA | PHARMACY LICENSE |
| 22 | NR2270 | OTHER | NEW HAMPSHIRE | PHARMACY LICENSE |
| 23 | PH33336 | OTHER | FLORIDA | PHARMACY LICENSE |
| 24 | PHA-MOP-LIC-84404 | OTHER | MONTANA | PHARMACY LICENSE |
| 25 | 266265 | OTHER | MINNESOTA | PHARMACY LICENSE |
| 26 | NR-51935 | OTHER | WYOMING | PHARMACY LICENSE |
| 27 | 103759236 | MEDICAID | PENNSYLVANIA | |
| 28 | 60006758A | OTHER | INDIANA | PHARMACY LICENSE |
| 29 | RP-0003705 | OTHER | OREGON | PHARMACY LICENSE |
| 30 | Y008405 | OTHER | ARIZONA | PHARMACY LICENSE |
| 31 | 28RO00224700 | OTHER | NEW JERSEY | PHARMACY LICENSE |
| 32 | PH0005403 | OTHER | NEW MEXICO | PHARMACY LICENSE |
| 33 | 038275 | OTHER | NEW YORK | PHARMACY LICENSE |
| 34 | 2021001793 | OTHER | MISSOURI | PHARMACY LICENSE |
| 35 | 2521-43 | OTHER | WISCONSIN | PHARMACY LICENSE |
| 36 | 58582MS | OTHER | IDAHO | PHARMACY LICENSE |
| 37 | MO40003141 | OTHER | MAINE | PHARMACY LICENSE |
| 38 | NP001573 | OTHER | PENNSYLVANIA | PHARMACY LICENSE |
| 39 | PHAR1918 | OTHER | NORTH DAKOTA | PHARMACY LICENSE |
| 40 | PHNR001945 | OTHER | GEORGIA | PHARMACY LICENSE |
| 41 | PMP-1895 | OTHER | HAWAII | PHARMACY LICENSE |
