=====================================================
General NPI Number Information
=====================================================
NPI Number | 1548529332
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GOOD HARVEST MARKET
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/14/2012
-----------------------------------------------------
Last Update Date | 05/14/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1850 MEADOW LN
-----------------------------------------------------
City | PEWAUKEE
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53072-5572
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 262-544-9380
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1850 MEADOW LANE
-----------------------------------------------------
City | PEWAUKEE
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53072
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 262-544-9380
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | BOOKKEEPER
-----------------------------------------------------
Name | BECKY FAMULARO
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 262-544-9380
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 335G00000X
-----------------------------------------------------
Taxonomy Name | Medical Foods Supplier
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------