Provider Demographics
NPI:1346383601
Name:MIX PHARMACY, LLC
Entity Type:Organization
Organization Name:MIX PHARMACY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ALANNA
Authorized Official - Middle Name:
Authorized Official - Last Name:HUMPHREY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:612-275-8910
Mailing Address - Street 1:1266 HELMO AVE N
Mailing Address - Street 2:
Mailing Address - City:OAKDALE
Mailing Address - State:MN
Mailing Address - Zip Code:55128
Mailing Address - Country:US
Mailing Address - Phone:651-645-9715
Mailing Address - Fax:651-925-8959
Practice Address - Street 1:1266 HELMO AVE N
Practice Address - Street 2:
Practice Address - City:OAKDALE
Practice Address - State:MN
Practice Address - Zip Code:55128
Practice Address - Country:US
Practice Address - Phone:651-645-9715
Practice Address - Fax:651-925-8659
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-15
Last Update Date:2018-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2650343336C0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3336C0004XSuppliersPharmacyCompounding PharmacyGroup - Single Specialty