=====================================================
General NPI Number Information
=====================================================
NPI Number | 1184893117
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MI ENTERPRISES LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/25/2008
-----------------------------------------------------
Last Update Date | 09/23/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8575 KNOTT AVE STE D
-----------------------------------------------------
City | BUENA PARK
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90620-3850
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 714-527-6078
-----------------------------------------------------
Fax | 714-527-7185
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8575 KNOTT AVE STE D
-----------------------------------------------------
City | BUENA PARK
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90620-3850
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 714-527-6078
-----------------------------------------------------
Fax | 714-527-7185
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRES
-----------------------------------------------------
Name | MARVEL JULY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 741-527-6078
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336L0003X
-----------------------------------------------------
Taxonomy Name | Long Term Care Pharmacy
-----------------------------------------------------
License Number | PHY48675
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------