Provider Demographics
NPI:1114246675
Name:MIRANDA, PORTIA
Entity Type:Individual
Prefix:
First Name:PORTIA
Middle Name:
Last Name:MIRANDA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:34757 KLONDIKE DR
Mailing Address - Street 2:
Mailing Address - City:UNION CITY
Mailing Address - State:CA
Mailing Address - Zip Code:94587-3664
Mailing Address - Country:US
Mailing Address - Phone:510-797-7956
Mailing Address - Fax:
Practice Address - Street 1:31091 MISSION BLVD
Practice Address - Street 2:
Practice Address - City:HAYWARD
Practice Address - State:CA
Practice Address - Zip Code:94544-7601
Practice Address - Country:US
Practice Address - Phone:510-489-4581
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-05-24
Last Update Date:2012-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA53177183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist