Healthcare Provider Details

I. General information

NPI: 1407365679
Provider Name (Legal Business Name): MIXLAB, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/20/2017
Last Update Date: 10/05/2020
Certification Date: 10/05/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

336 W 37TH ST RM 850
NEW YORK NY
10018-4280
US

IV. Provider business mailing address

336 W 37TH ST RM 850
NEW YORK NY
10018-4280
US

V. Phone/Fax

Practice location:
  • Phone: 888-901-4480
  • Fax:
Mailing address:
  • Phone: 888-901-4480
  • Fax: 212-967-0892

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number035768
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number035768
License Number StateNY
# 3
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number035768
License Number StateNY

VIII. Authorized Official

Name: VINNIE DAM
Title or Position: CHIEF PHARMACY OFFICER
Credential: PHARMD, MS
Phone: 347-610-9820