Provider Demographics
NPI:1326320847
Name:DAMNJANOVIC, MIRA
Entity Type:Individual
Prefix:
First Name:MIRA
Middle Name:
Last Name:DAMNJANOVIC
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 1:638 N ARBOGAST ST
Mailing Address - Street 2:
Mailing Address - City:GRIFFITH
Mailing Address - State:IN
Mailing Address - Zip Code:46319-2406
Mailing Address - Country:US
Mailing Address - Phone:219-923-5717
Mailing Address - Fax:
Practice Address - Street 1:2123 E COLUMBUS DR
Practice Address - Street 2:
Practice Address - City:EAST CHICAGO
Practice Address - State:IN
Practice Address - Zip Code:46312-2831
Practice Address - Country:US
Practice Address - Phone:219-397-6911
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-10
Last Update Date:2011-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26022302A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist