{
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"IsOrgSubpart": "N",
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"FirstName": null,
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"NamePrefix": null,
"NameSuffix": null,
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"FirstLineMailingAddress": "30290 JOSIE BILLIE HWY",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "CLEWISTON",
"MailingAddressStateName": "FL",
"MailingAddressPostalCode": "33440-9502",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "863-983-1197",
"MailingAddressFaxNumber": "863-983-1214",
"FirstLinePracticeLocationAddress": "31055 JOSIE BILLIE HIGHWAY",
"SecondLinePracticeLocationAddress": null,
"PracticeLocationAddressCityName": "CLEWISTON",
"PracticeLocationAddressStateName": "FL",
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"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "863-983-1197",
"PracticeLocationAddressFaxNumber": "863-983-1214",
"EnumerationDate": "06/06/2017",
"LastUpdateDate": "07/21/2022",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "OBAN",
"AuthorizedOfficialFirstName": "MONICA",
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"AuthorizedOfficialTitle": "PHARMACY PROGRAM MANAGER",
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"AuthorizedOfficialCredential": null,
"AuthorizedOfficialTelephoneNumber": "954-965-1331",
"Taxonomies": {
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{
"TaxonomyCode": "333600000X",
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"LicenseNumberStateCode": null,
"PrimaryTaxonomySwitch": "N"
},
{
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},
{
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"PrimaryTaxonomySwitch": "Y"
}
]
},
"HealthcareProviderTaxonomyGroups": null
}
}