Healthcare Provider Details

I. General information

NPI: 1366129322
Provider Name (Legal Business Name): MIXLAB, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/30/2023
Last Update Date: 09/06/2023
Certification Date: 10/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3880 N 28TH TER
HOLLYWOOD FL
33020-1118
US

IV. Provider business mailing address

3880 N 28TH TER
HOLLYWOOD FL
33020-1118
US

V. Phone/Fax

Practice location:
  • Phone: 888-901-4480
  • Fax: 212-267-0892
Mailing address:
  • Phone: 888-901-4480
  • Fax: 212-267-0892

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State

VIII. Authorized Official

Name: VINNIE DAM
Title or Position: CHIEF PHARMACY OFFICER
Credential:
Phone: 888-901-4480