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General NPI Number Information
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NPI Number | 1417192980
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Entity Type | Organization
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Legal Business Name | STATE OF NEVADA
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Dates
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Enumeration Date | 12/11/2008
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Last Update Date | 07/13/2016
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Provider Practice Location Address
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Address Line | 1590 W SUNSET RD
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City | HENDERSON
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State | NV
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Zip | 89014-6633
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Country | US
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Telephone | 702-486-6860
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Fax | 702-486-6862
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Provider Business Mailing Address
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Address Line | 1590 W SUNSET RD
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City | HENDERSON
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State | NV
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Zip | 89014-6633
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Country | US
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Telephone | 702-486-6860
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Fax | 702-486-6862
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Authorized Official
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Title or Position | STATEWIDE PHARMACY DIRECTOR
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Name | CHARLES COSTAS
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Credential |
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Telephone | 702-486-6301
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 3336C0002X
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Taxonomy Name | Clinic Pharmacy
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License Number | PH01180
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License Number State | NV
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