MEDICARE: MIRA DAMNJANOVIC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	26022302A	IN

General Provider Information

NPI Number	:	1326320847
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MIRA DAMNJANOVIC

Provider Business Mailing Address
First Line	:	638 N ARBOGAST ST
Second Line	:
City	:	GRIFFITH
State	:	IN
Zip	:	46319-2406
Country	:	US
Telephone Number	:	219-923-5717
Fax Number	:

Provider Business Practice Location Address
First Line	:	2123 E COLUMBUS DR
Second Line	:
City	:	EAST CHICAGO
State	:	IN
Zip	:	46312-2831
Country	:	US
Telephone Number	:	219-397-6911
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/10/2011
Last Update Date	:	09/10/2011

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Directions to “ MIRA DAMNJANOVIC ” Practice Location

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