Provider Demographics
NPI:1104218056
Name:MIRACLE PHARMACY INC
Entity Type:Organization
Organization Name:MIRACLE PHARMACY INC
Other - Org Name:FAMILY PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:FOZIA
Authorized Official - Middle Name:
Authorized Official - Last Name:MIRZA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:201-410-6995
Mailing Address - Street 1:9622 METROPOLITAN AVE
Mailing Address - Street 2:
Mailing Address - City:FOREST HILLS
Mailing Address - State:NY
Mailing Address - Zip Code:11375-6625
Mailing Address - Country:US
Mailing Address - Phone:718-268-2151
Mailing Address - Fax:
Practice Address - Street 1:9622 METROPOLITAN AVE
Practice Address - Street 2:
Practice Address - City:FOREST HILLS
Practice Address - State:NY
Practice Address - Zip Code:11375-6625
Practice Address - Country:US
Practice Address - Phone:718-268-2151
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-02
Last Update Date:2015-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY048579-1333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY740850001OtherPTAN
NY7408510001Medicare NSC