Healthcare Provider Details

I. General information

NPI: 1750676805
Provider Name (Legal Business Name): MAVIXEN MIRANDA GREGG RPH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/16/2011
Last Update Date: 06/16/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7025 EL CAMINO REAL
ATASCADERO CA
93422-4523
US

IV. Provider business mailing address

8805 ATASCADERO AVE
ATASCADERO CA
93422-5036
US

V. Phone/Fax

Practice location:
  • Phone: 805-466-8722
  • Fax:
Mailing address:
  • Phone: 805-952-5409
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number59230
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: