MEDICARE: MIXLAB, INC.

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	3336C0003X	Community/Retail Pharmacy
2	3336C0004X	Compounding Pharmacy
3	3336S0011X	Specialty Pharmacy
4	333600000X	Pharmacy

General Provider Information

NPI Number	:	1649807140
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MIXLAB, INC.

Provider Business Mailing Address
First Line	:	2223 FEDERAL AVE
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90064-1403
Country	:	US
Telephone Number	:	888-901-4480
Fax Number	:	212-967-0892

Provider Business Practice Location Address
First Line	:	2223 FEDERAL AVE
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90064-1403
Country	:	US
Telephone Number	:	888-901-4480
Fax Number	:	212-967-0892

Authorized Official
Title or Position	:	CHIEF PHARMACY OFFICER
Name	:	VINH DAM
Credential	:	PHARMD, MS
Telephone Number	:	347-610-9820

Provider Enumeration Date	:	03/25/2020
Last Update Date	:	03/25/2020

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Directions to “MIXLAB, INC. ” Practice Location

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