Provider Demographics
NPI:1679764443
Name:MIRACLE PHARMACY INC.
Entity Type:Organization
Organization Name:MIRACLE PHARMACY INC.
Other - Org Name:WEST VERN PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:NANCY
Authorized Official - Middle Name:NAZIK
Authorized Official - Last Name:SIMONIAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:818-541-0555
Mailing Address - Street 1:2490 HONOLULU AVE # 140-B
Mailing Address - Street 2:
Mailing Address - City:MONTROSE
Mailing Address - State:CA
Mailing Address - Zip Code:91020-1800
Mailing Address - Country:US
Mailing Address - Phone:818-541-0555
Mailing Address - Fax:
Practice Address - Street 1:2490 HONOLULU AVE # 140-B
Practice Address - Street 2:
Practice Address - City:MONTROSE
Practice Address - State:CA
Practice Address - Zip Code:91020-1800
Practice Address - Country:US
Practice Address - Phone:818-541-0555
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-07
Last Update Date:2008-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA483383336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA6057200001Medicare NSC