Basic Information
| Provider Information | |||||||||
| NPI: | 1184358285 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LI | ||||||||
| FirstName: | ENBO | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PHARM.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10573 CHADWICK FALLS ST | ||||||||
| Address2: | |||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891791511 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7073185441 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3186 S MARYLAND PKWY | ||||||||
| Address2: | |||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891092306 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7029615000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/13/2022 | ||||||||
| LastUpdateDate: | 07/14/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/14/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183500000X | 76251 | CA | Y | Pharmacy Service Providers | Pharmacist |
No ID Information.