=====================================================
General NPI Number Information
=====================================================
NPI Number | 1801231428
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MDM PHARMACY SERVICES LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/09/2013
-----------------------------------------------------
Last Update Date | 06/30/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 57725 29 PALMS HWY STE 209
-----------------------------------------------------
City | YUCCA VALLEY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92284-3044
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 760-228-1600
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 57725 29 PALMS HWY SUITE 209
-----------------------------------------------------
City | YUCCA VALLEY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92284-3044
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 760-228-1600
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHARMACIST IN CHARGE / OWNER
-----------------------------------------------------
Name | MAHER MICHAIL
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 760-851-8120
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 333600000X
-----------------------------------------------------
Taxonomy Name | Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 3336C0004X
-----------------------------------------------------
Taxonomy Name | Compounding Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | 51439
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------