=====================================================
General NPI Number Information
=====================================================
NPI Number | 1821655051
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FUTURE GATE ENTERPRISES LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/22/2019
-----------------------------------------------------
Last Update Date | 05/22/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7920 S MASON MONTGOMERY RD
-----------------------------------------------------
City | MASON
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45040-8249
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 513-546-2422
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7920 S MASON MONTGOMERY RD
-----------------------------------------------------
City | MASON
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45040-8249
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 513-546-2422
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | ANGI HAFEZ
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 513-546-2422
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 333600000X
-----------------------------------------------------
Taxonomy Name | Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------