Provider Demographics
NPI:1750676805
Name:GREGG, MAVIXEN MIRANDA (RPH)
Entity Type:Individual
Prefix:
First Name:MAVIXEN
Middle Name:MIRANDA
Last Name:GREGG
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8805 ATASCADERO AVE
Mailing Address - Street 2:
Mailing Address - City:ATASCADERO
Mailing Address - State:CA
Mailing Address - Zip Code:93422-5036
Mailing Address - Country:US
Mailing Address - Phone:805-952-5409
Mailing Address - Fax:
Practice Address - Street 1:7025 EL CAMINO REAL
Practice Address - Street 2:
Practice Address - City:ATASCADERO
Practice Address - State:CA
Practice Address - Zip Code:93422-4523
Practice Address - Country:US
Practice Address - Phone:805-466-8722
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-16
Last Update Date:2011-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA59230183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist