Healthcare Provider Details

I. General information

NPI: 1114521507
Provider Name (Legal Business Name): MICHELLE MIZO PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/25/2020
Last Update Date: 11/25/2020
Certification Date: 11/25/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 S PAVILION CENTER DR
LAS VEGAS NV
89144-4566
US

IV. Provider business mailing address

9031 KINGSDALE CT
LAS VEGAS NV
89147-6837
US

V. Phone/Fax

Practice location:
  • Phone: 702-352-2053
  • Fax:
Mailing address:
  • Phone: 702-234-6369
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberS020173
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number18632
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: