Healthcare Provider Details

I. General information

NPI: 1871959189
Provider Name (Legal Business Name): MZMZ CORP.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/04/2016
Last Update Date: 01/15/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17609 VENTURA BLVD STE LL06
ENCINO CA
91316-5137
US

IV. Provider business mailing address

17609 VENTURA BLVD LL06
ENCINO CA
91316-3858
US

V. Phone/Fax

Practice location:
  • Phone: 818-464-4988
  • Fax: 818-464-4989
Mailing address:
  • Phone: 818-464-4988
  • Fax: 818-464-4989

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number58321
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: DANIEL LERNER
Title or Position: PRESIDENT
Credential:
Phone: 424-268-6028