Provider Demographics
NPI:1689651309
Name:MIM, NY (PHARM D)
Entity Type:Individual
Prefix:
First Name:NY
Middle Name:
Last Name:MIM
Suffix:
Gender:M
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4000 BELLA TUSCANY DR
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95356-9339
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2100 STANDIFORD AVE
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350-6522
Practice Address - Country:US
Practice Address - Phone:209-577-1350
Practice Address - Fax:209-577-1409
Is Sole Proprietor?:No
Enumeration Date:2005-12-22
Last Update Date:2007-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA48317183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist