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General NPI Number Information
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NPI Number | 1902109952
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Entity Type | Organization
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Legal Business Name | MIRRA RX INC
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Dates
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Enumeration Date | 12/14/2010
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Last Update Date | 07/10/2013
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Provider Practice Location Address
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Address Line | 14 MADISON AVE
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City | VALHALLA
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State | NY
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Zip | 10595-1900
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Country | US
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Telephone | 800-361-1260
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Fax |
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Provider Business Mailing Address
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Address Line | 14 MADISON AVE
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City | VALHALLA
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State | NY
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Zip | 10595-1900
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Country | US
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Telephone | 800-361-1260
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | MR. JERRY DOMINICK MIRRA
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Credential | RPH
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Telephone | 914-980-8321
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 3336S0011X
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Taxonomy Name | Specialty Pharmacy
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License Number | 030332
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License Number State | NY
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