Provider Demographics
NPI:1154860393
Name:MUNOZ, MYRANDA
Entity Type:Individual
Prefix:
First Name:MYRANDA
Middle Name:
Last Name:MUNOZ
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 1:1020 W PERKINS ST
Mailing Address - Street 2:
Mailing Address - City:UKIAH
Mailing Address - State:CA
Mailing Address - Zip Code:95482-4623
Mailing Address - Country:US
Mailing Address - Phone:620-272-1282
Mailing Address - Fax:
Practice Address - Street 1:653 S STATE ST
Practice Address - Street 2:
Practice Address - City:UKIAH
Practice Address - State:CA
Practice Address - Zip Code:95482-4912
Practice Address - Country:US
Practice Address - Phone:707-467-2712
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-21
Last Update Date:2017-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA75924183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist