Provider Demographics
NPI:1114917358
Name:MISINKO INC
Entity Type:Organization
Organization Name:MISINKO INC
Other - Org Name:ST JAMES PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:TREASURER
Authorized Official - Prefix:
Authorized Official - First Name:PRATISH
Authorized Official - Middle Name:
Authorized Official - Last Name:MISTRY
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:323-773-1700
Mailing Address - Street 1:7611 ATLANTIC AVE
Mailing Address - Street 2:
Mailing Address - City:CUDAHY
Mailing Address - State:CA
Mailing Address - Zip Code:90201-5019
Mailing Address - Country:US
Mailing Address - Phone:323-773-1700
Mailing Address - Fax:323-773-5959
Practice Address - Street 1:7611 ATLANTIC AVE
Practice Address - Street 2:
Practice Address - City:CUDAHY
Practice Address - State:CA
Practice Address - Zip Code:90201-5019
Practice Address - Country:US
Practice Address - Phone:323-773-1700
Practice Address - Fax:323-773-5959
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-27
Last Update Date:2016-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
CAPHY432823336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2075229OtherPK
CAPHA432820Medicaid
5529320001Medicare NSC