=====================================================
General NPI Number Information
=====================================================
NPI Number | 1144902248
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | VAX SQUAD
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/07/2023
-----------------------------------------------------
Last Update Date | 10/04/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3450 E RUSSELL RD # 102
-----------------------------------------------------
City | LAS VEGAS
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89120-2201
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 725-867-9411
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2989 VIA DELLA AMORE
-----------------------------------------------------
City | HENDERSON
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89052-4029
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHARMACIST/CO-OWNER
-----------------------------------------------------
Name | KARIM GUIRGUIS
-----------------------------------------------------
Credential | PHARM.D.
-----------------------------------------------------
Telephone | 702-480-7086
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 333600000X
-----------------------------------------------------
Taxonomy Name | Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------