Provider Demographics
NPI:1033591540
Name:MDM PHARMACY SERVICES 2
Entity Type:Organization
Organization Name:MDM PHARMACY SERVICES 2
Other - Org Name:NEW PHARMACY 2
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER / PIC/ AO
Authorized Official - Prefix:
Authorized Official - First Name:MAHER
Authorized Official - Middle Name:
Authorized Official - Last Name:MICHAIL
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:760-851-8120
Mailing Address - Street 1:57725 29 PALMS HWY
Mailing Address - Street 2:STE 209
Mailing Address - City:YUCCA VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92284-3044
Mailing Address - Country:US
Mailing Address - Phone:760-228-1600
Mailing Address - Fax:760-228-0400
Practice Address - Street 1:72724 29 PALMS HWY STE 104
Practice Address - Street 2:
Practice Address - City:TWENTYNINE PALMS
Practice Address - State:CA
Practice Address - Zip Code:92277-2459
Practice Address - Country:US
Practice Address - Phone:760-367-2000
Practice Address - Fax:760-367-2001
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-20
Last Update Date:2017-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
CAPHY525553336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2152780OtherPK