Provider Demographics
NPI:1104184357
Name:SIMON, HARVIE NULUD (RPH)
Entity Type:Individual
Prefix:
First Name:HARVIE
Middle Name:NULUD
Last Name:SIMON
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12345 MAGNOLIA BLVD
Mailing Address - Street 2:APT 29
Mailing Address - City:VALLEY VILLAGE
Mailing Address - State:CA
Mailing Address - Zip Code:91607-4206
Mailing Address - Country:US
Mailing Address - Phone:818-653-1157
Mailing Address - Fax:
Practice Address - Street 1:12345 MAGNOLIA BLVD
Practice Address - Street 2:APT 29
Practice Address - City:VALLEY VILLAGE
Practice Address - State:CA
Practice Address - Zip Code:91607-4206
Practice Address - Country:US
Practice Address - Phone:818-653-1157
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-04-25
Last Update Date:2012-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA66746183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist