Healthcare Provider Details

I. General information

NPI: 1669357125
Provider Name (Legal Business Name): MIREILLE HENRIETTE LINE ZOA PHARMACIST
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/06/2025
Last Update Date: 08/06/2025
Certification Date: 08/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2360 JUSTIN RD
LEWISVILLE TX
75077-3071
US

IV. Provider business mailing address

2360 JUSTIN RD
LEWISVILLE TX
75077-3071
US

V. Phone/Fax

Practice location:
  • Phone: 972-966-0526
  • Fax: 972-966-2114
Mailing address:
  • Phone: 972-966-0526
  • Fax: 972-966-2114

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number75868
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: