Provider Demographics
NPI:1619053154
Name:BOISCLAIR, MIRANDA DIANE (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:MIRANDA
Middle Name:DIANE
Last Name:BOISCLAIR
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 1:535 GAYLEY AVE APT 207
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90024-2040
Mailing Address - Country:US
Mailing Address - Phone:843-597-0429
Mailing Address - Fax:
Practice Address - Street 1:11301 WILSHIRE BLVD BLDG 500
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90073-1003
Practice Address - Country:US
Practice Address - Phone:310-362-0179
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC0114391835G0303X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835G0303XPharmacy Service ProvidersPharmacistGeriatric