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General NPI Number Information
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NPI Number | 1245086552
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Entity Type | Organization
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Legal Business Name | MIXLAB TX, LLC
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Dates
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Enumeration Date | 04/26/2024
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Last Update Date | 04/26/2024
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Provider Practice Location Address
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Address Line | 953 HILLTOP DR
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City | WEATHERFORD
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State | TX
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Zip | 76086-8811
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Country | US
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Telephone | 888-901-4480
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Fax |
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Provider Business Mailing Address
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Address Line | 953 HILLTOP DR
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City | WEATHERFORD
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State | TX
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Zip | 76086-8811
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Country | US
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Telephone | 888-901-4480
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Fax |
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Authorized Official
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Title or Position | CHIEF PHARMACY OFFICER
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Name | VINNEI DAM
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Credential | PHARMD, MS
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Telephone | 347-610-9820
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 3336C0004X
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Taxonomy Name | Compounding Pharmacy
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 333600000X
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Taxonomy Name | Pharmacy
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License Number |
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License Number State |
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