Healthcare Provider Details

I. General information

NPI: 1134043110
Provider Name (Legal Business Name): MARYANN MIRZAKANDOV
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/04/2026
Last Update Date: 08/04/2026
Certification Date: 08/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18615 N 34TH AVE UNIT 2
PHOENIX AZ
85027-4867
US

IV. Provider business mailing address

18615 N 34TH AVE UNIT 2
PHOENIX AZ
85027-4867
US

V. Phone/Fax

Practice location:
  • Phone: 602-515-6880
  • Fax:
Mailing address:
  • Phone: 602-515-6880
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: