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General NPI Number Information
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NPI Number | 1154733905
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Entity Type | Organization
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Legal Business Name | DIVINE PROVIDENCE INC
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Dates
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Enumeration Date | 05/28/2014
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Last Update Date | 09/21/2016
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Provider Practice Location Address
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Address Line | 1729 E CHARLESTON BLVD STE F
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City | LAS VEGAS
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State | NV
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Zip | 89104-1986
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Country | US
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Telephone | 702-778-3072
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Fax | 702-778-0512
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Provider Business Mailing Address
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Address Line | 1729 E CHARLESTON BLVD STE F
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City | LAS VEGAS
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State | NV
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Zip | 89104-1986
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Country | US
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Telephone | 702-778-3072
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Fax | 702-778-0512
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Authorized Official
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Title or Position | CHIEF PHARMACIST
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Name | MODUPE IROROBEJE
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Credential |
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Telephone | 702-778-3072
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 333600000X
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Taxonomy Name | Pharmacy
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 3336C0003X
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Taxonomy Name | Community/Retail Pharmacy
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License Number | PH03196
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License Number State | NV
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