Provider Demographics
NPI:1063852689
Name:MIJ LLC
Entity Type:Organization
Organization Name:MIJ LLC
Other - Org Name:PROGRESSIVE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SHAKIR
Authorized Official - Middle Name:
Authorized Official - Last Name:MEGHANI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:334-718-9768
Mailing Address - Street 1:2812 HARTFORD HWY
Mailing Address - Street 2:SUITE 1
Mailing Address - City:DOTHAN
Mailing Address - State:AL
Mailing Address - Zip Code:36305-4927
Mailing Address - Country:US
Mailing Address - Phone:334-699-8622
Mailing Address - Fax:
Practice Address - Street 1:1970 ANDREWS AVE
Practice Address - Street 2:
Practice Address - City:OZARK
Practice Address - State:AL
Practice Address - Zip Code:36360-3726
Practice Address - Country:US
Practice Address - Phone:334-350-3671
Practice Address - Fax:334-350-3672
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-27
Last Update Date:2017-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
AL2026233336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2147359OtherPK
AL166432Medicaid