{
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"IsOrgSubpart": "N",
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"FirstLineMailingAddress": "PO BOX 825159",
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"MailingAddressCityName": "PHILADELPHIA",
"MailingAddressStateName": "PA",
"MailingAddressPostalCode": "19182-5159",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": null,
"MailingAddressFaxNumber": null,
"FirstLinePracticeLocationAddress": "44 TRIFECTA PL STE 200",
"SecondLinePracticeLocationAddress": null,
"PracticeLocationAddressCityName": "CHARLES TOWN",
"PracticeLocationAddressStateName": "WV",
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"PracticeLocationAddressFaxNumber": null,
"EnumerationDate": "05/07/2025",
"LastUpdateDate": "05/07/2025",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "BOYCE",
"AuthorizedOfficialFirstName": "KIYA",
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"AuthorizedOfficialTitle": "REGIONAL CREDENTIALING SPECIALIST",
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"AuthorizedOfficialTelephoneNumber": "301-933-7133",
"Taxonomies": {
"Taxonomy": {
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"TaxonomyName": "Non-Pharmacy Dispensing Site",
"LicenseNumber": null,
"LicenseNumberStateCode": null,
"PrimaryTaxonomySwitch": "Y"
}
},
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}
}