Provider Demographics
NPI:1235912312
Name:ZIEDAN, MIA
Entity Type:Individual
Prefix:
First Name:MIA
Middle Name:
Last Name:ZIEDAN
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 1:1311 S JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75766-3050
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1311 S JACKSON ST
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:TX
Practice Address - Zip Code:75766-3050
Practice Address - Country:US
Practice Address - Phone:903-586-1164
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-14
Last Update Date:2023-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX72757183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist