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General NPI Number Information
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NPI Number | 1649807140
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Entity Type | Organization
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Legal Business Name | MIXLAB, INC.
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Dates
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Enumeration Date | 03/25/2020
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Last Update Date | 03/25/2020
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Provider Practice Location Address
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Address Line | 2223 FEDERAL AVE
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City | LOS ANGELES
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State | CA
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Zip | 90064-1403
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Country | US
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Telephone | 888-901-4480
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Fax | 212-967-0892
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Provider Business Mailing Address
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Address Line | 2223 FEDERAL AVE
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City | LOS ANGELES
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State | CA
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Zip | 90064-1403
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Country | US
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Telephone | 888-901-4480
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Fax | 212-967-0892
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Authorized Official
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Title or Position | CHIEF PHARMACY OFFICER
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Name | VINH 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 | 3336C0003X
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Taxonomy Name | Community/Retail 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 | 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 #3
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Taxonomy Code | 3336S0011X
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Taxonomy Name | Specialty Pharmacy
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License Number |
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License Number State |
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Taxonomy #4
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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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