=====================================================
General NPI Number Information
=====================================================
NPI Number | 1902353279
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | VINEET GUPTA R.PH, PH.D
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/04/2016
-----------------------------------------------------
Last Update Date | 09/04/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4600 KELL BLVD
-----------------------------------------------------
City | WICHITA FALLS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76310-1466
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 940-692-4610
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3001 KEMP BLVD APT 1101
-----------------------------------------------------
City | WICHITA FALLS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76308-1063
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 216-802-8897
-----------------------------------------------------
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 | 57780
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | S021828
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------