=====================================================
General NPI Number Information
=====================================================
NPI Number | 1306220843
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DIVINE TOUCH SERVICES PHARMACY & COMPOUNDING
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/15/2015
-----------------------------------------------------
Last Update Date | 09/04/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2208 E CHARLESTON BLVD STE B
-----------------------------------------------------
City | LAS VEGAS
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89104-2049
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 702-331-0887
-----------------------------------------------------
Fax | 702-331-5127
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2208 E CHARLESTON BLVD STE B
-----------------------------------------------------
City | LAS VEGAS
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89104-2049
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 702-331-0887
-----------------------------------------------------
Fax | 702-331-5127
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO/ PHARMACIST
-----------------------------------------------------
Name | JOSHUA AIGHOBAHI
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 702-331-0887
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332B00000X
-----------------------------------------------------
Taxonomy Name | Durable Medical Equipment & Medical Supplies
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 333600000X
-----------------------------------------------------
Taxonomy Name | Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 3336C0004X
-----------------------------------------------------
Taxonomy Name | Compounding Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | PH03411
-----------------------------------------------------
License Number State | NV
-----------------------------------------------------