Healthcare Provider Details

I. General information

NPI: 1184153207
Provider Name (Legal Business Name): MIREILLE ISHAC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/12/2017
Last Update Date: 06/12/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6588 FOOTHILL BLVD
TUJUNGA CA
91042-2705
US

IV. Provider business mailing address

3943 SAN FERNANDO RD
GLENDALE CA
91204-2721
US

V. Phone/Fax

Practice location:
  • Phone: 818-446-0647
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number60635
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: