MEDICARE: NEVADA FAMILY PRACTICE RESIDENCE PROGRAM

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	333600000X	Pharmacy	PH1189	NV

General Provider Information

NPI Number	:	1083683874
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NEVADA FAMILY PRACTICE RESIDENCE PROGRAM

Provider Business Mailing Address
First Line	:	4000 E CHARLESTON BLVD
Second Line	:	B-130
City	:	LAS VEGAS
State	:	NV
Zip	:	89104-6659
Country	:	US
Telephone Number	:	702-968-4038
Fax Number	:	702-968-4033

Provider Business Practice Location Address
First Line	:	4000 E CHARLESTON BLVD
Second Line	:	B-130
City	:	LAS VEGAS
State	:	NV
Zip	:	89104-6659
Country	:	US
Telephone Number	:	702-968-4038
Fax Number	:	702-968-4033

Authorized Official
Title or Position	:	PHARMACIST/MANAGER
Name	:	MR. KENNETH J. RYAN
Credential	:	RPH
Telephone Number	:	702-968-4038

Provider Enumeration Date	:	03/15/2006
Last Update Date	:	10/05/2010

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