=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114741626
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MINA S GOBRAN PHARMD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/12/2024
-----------------------------------------------------
Last Update Date | 11/12/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3950 GRANDVIEW DR
-----------------------------------------------------
City | SIMPSONVILLE
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29680-3163
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 864-962-0272
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9 GREAT OAKS WAY
-----------------------------------------------------
City | SIMPSONVILLE
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29680-6256
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 864-901-1210
-----------------------------------------------------
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 | 60431
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------