=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083997167
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARK ANTUN B.S.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/24/2011
-----------------------------------------------------
Last Update Date | 09/24/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 148 W CENTRAL ST
-----------------------------------------------------
City | NATICK
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 01760-4106
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 508-653-3303
-----------------------------------------------------
Fax | 508-652-0816
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 148 W CENTRAL ST
-----------------------------------------------------
City | NATICK
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 01760-4106
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 24776
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------