=====================================================
General NPI Number Information
=====================================================
NPI Number | 1518090570
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | NATHAN Z IMRE PHARMD.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/13/2007
-----------------------------------------------------
Last Update Date | 02/14/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4500 N LEWIS AVE
-----------------------------------------------------
City | SIOUX FALL
-----------------------------------------------------
State | SD
-----------------------------------------------------
Zip | 57104
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-308-7690
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 411 WALNUT ST
-----------------------------------------------------
City | GREEN COVE SPRINGS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32043-3443
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-308-7690
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 9203
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------