Healthcare Provider Details

I. General information

NPI: 1245086552
Provider Name (Legal Business Name): MIXLAB TX, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/26/2024
Last Update Date: 04/26/2024
Certification Date: 04/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

953 HILLTOP DR
WEATHERFORD TX
76086-8811
US

IV. Provider business mailing address

953 HILLTOP DR
WEATHERFORD TX
76086-8811
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State

VIII. Authorized Official

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