Provider Demographics
NPI:1083683874
Name:NEVADA FAMILY PRACTICE RESIDENCE PROGRAM
Entity Type:Organization
Organization Name:NEVADA FAMILY PRACTICE RESIDENCE PROGRAM
Other - Org Name:CAMPUS PHARMACY III
Other - Org Type:Other Name
Authorized Official - Title/Position:PHARMACIST/MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:J
Authorized Official - Last Name:RYAN
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:702-968-4038
Mailing Address - Street 1:4000 E CHARLESTON BLVD
Mailing Address - Street 2:B-130
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89104-6659
Mailing Address - Country:US
Mailing Address - Phone:702-968-4038
Mailing Address - Fax:702-968-4033
Practice Address - Street 1:4000 E CHARLESTON BLVD
Practice Address - Street 2:B-130
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89104-6659
Practice Address - Country:US
Practice Address - Phone:702-968-4038
Practice Address - Fax:702-968-4033
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-15
Last Update Date:2010-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVPH1189333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV5793810001Medicare NSC