MEDICARE: MR. MALLA MITTA RPH

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	5302038531	MI

General Provider Information

NPI Number	:	1942871876
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. MALLA MITTA RPH

Provider Business Mailing Address
First Line	:	1524 10TH ST
Second Line	:
City	:	PORT HURON
State	:	MI
Zip	:	48060-5815
Country	:	US
Telephone Number	:	810-982-3100
Fax Number	:	810-982-3106

Provider Business Practice Location Address
First Line	:	1524 10TH ST
Second Line	:
City	:	PORT HURON
State	:	MI
Zip	:	48060-5815
Country	:	US
Telephone Number	:	810-982-3100
Fax Number	:	810-982-3106

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

Provider Enumeration Date	:	07/01/2021
Last Update Date	:	07/01/2021

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