| Name | Value |
|---|---|
| PROVIDER TYPE | Pharmacy Service Providers |
| CLASSIFICATION | Pharmacist |
| AREA OF SPECIALIZATION | General Practice |
| STATUS | Inactive |
| DATE INACTIVATED | 2009-04-22 00:00:00 |
| VA CODE | V090101 |
| X12 CODE | 1835G0000X |
| INDIVIDUAL/NON | INDIVIDUAL |
| MASTER ENTRY FOR VUID | YES |
| VUID | 5253284 |
| EFFECTIVE DATE/TIME |
|