Healthcare Provider Details

I. General information

NPI: 1114246675
Provider Name (Legal Business Name): PORTIA MIRANDA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/24/2010
Last Update Date: 09/30/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

31091 MISSION BLVD
HAYWARD CA
94544-7601
US

IV. Provider business mailing address

34757 KLONDIKE DR
UNION CITY CA
94587-3664
US

V. Phone/Fax

Practice location:
  • Phone: 510-489-4581
  • Fax:
Mailing address:
  • Phone: 510-797-7956
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number53177
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: