Provider Demographics
NPI:1407365679
Name:MIXLAB, INC.
Entity Type:Organization
Organization Name:MIXLAB, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF PHARMACY OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:VINNIE
Authorized Official - Middle Name:
Authorized Official - Last Name:DAM
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD, MS
Authorized Official - Phone:347-610-9820
Mailing Address - Street 1:336 W 37TH ST RM 850
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10018-4280
Mailing Address - Country:US
Mailing Address - Phone:888-901-4480
Mailing Address - Fax:212-967-0892
Practice Address - Street 1:336 W 37TH ST RM 850
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10018-4280
Practice Address - Country:US
Practice Address - Phone:888-901-4480
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-09-20
Last Update Date:2020-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY035768333600000X, 3336C0003X, 3336C0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy