Provider Demographics
NPI:1538657606
Name:MICHAEL, MINA
Entity Type:Individual
Prefix:
First Name:MINA
Middle Name:
Last Name:MICHAEL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:MINA
Other - Middle Name:M
Other - Last Name:MIKHAEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:58501 29 PALMS HWY
Mailing Address - Street 2:
Mailing Address - City:YUCCA VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92284-5765
Mailing Address - Country:US
Mailing Address - Phone:760-365-7551
Mailing Address - Fax:760-365-6932
Practice Address - Street 1:58501 29 PALMS HWY
Practice Address - Street 2:
Practice Address - City:YUCCA VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92284-5765
Practice Address - Country:US
Practice Address - Phone:760-365-7551
Practice Address - Fax:760-365-6932
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-24
Last Update Date:2018-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA72657183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist