Provider Demographics
NPI:1083217996
Name:LEIVA, MYRNA (RPH)
Entity Type:Individual
Prefix:
First Name:MYRNA
Middle Name:
Last Name:LEIVA
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19820 NE 22ND AVE
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33180-2137
Mailing Address - Country:US
Mailing Address - Phone:786-200-8238
Mailing Address - Fax:
Practice Address - Street 1:18500 COLLINS AVE
Practice Address - Street 2:
Practice Address - City:SUNNY ISLES BEACH
Practice Address - State:FL
Practice Address - Zip Code:33160-2427
Practice Address - Country:US
Practice Address - Phone:305-935-0322
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-21
Last Update Date:2020-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS41725183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist