Healthcare Provider Details

I. General information

NPI: 1659436079
Provider Name (Legal Business Name): MIKMARA INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/26/2006
Last Update Date: 11/24/2020
Certification Date: 11/24/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

333 C ST STE 100
SAN DIEGO CA
92101-4809
US

IV. Provider business mailing address

333 C ST STE 100
SAN DIEGO CA
92101-4809
US

V. Phone/Fax

Practice location:
  • Phone: 619-232-8101
  • Fax: 619-232-8855
Mailing address:
  • Phone: 619-232-8101
  • Fax: 619-232-8855

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberPHY48339
License Number StateCA

VIII. Authorized Official

Name: KIM PHUNG
Title or Position: OWNER
Credential:
Phone: 619-708-1797