Healthcare Provider Details

I. General information

NPI: 1932925633
Provider Name (Legal Business Name): MIXLAB WI, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/26/2024
Last Update Date: 11/26/2024
Certification Date: 11/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

407 W SILVER SPRING DR
MILWAUKEE WI
53217-5048
US

IV. Provider business mailing address

407 W SILVER SPRING DR
MILWAUKEE WI
53217-5048
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State

VIII. Authorized Official

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