Provider Demographics
NPI:1407311848
Name:MIR, LILLY (PHARMD)
Entity Type:Individual
Prefix:
First Name:LILLY
Middle Name:
Last Name:MIR
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:431 BUENA VISTA AVE
Mailing Address - Street 2:
Mailing Address - City:REDWOOD CITY
Mailing Address - State:CA
Mailing Address - Zip Code:94061-4207
Mailing Address - Country:US
Mailing Address - Phone:650-867-7338
Mailing Address - Fax:
Practice Address - Street 1:1100 VETERANS BLVD
Practice Address - Street 2:
Practice Address - City:REDWOOD CITY
Practice Address - State:CA
Practice Address - Zip Code:94063-2037
Practice Address - Country:US
Practice Address - Phone:650-299-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-08
Last Update Date:2019-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA56651183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist