Provider Demographics
NPI:1790271260
Name:MICHAEL, MARIAM MAHER KANDAS (RPH)
Entity Type:Individual
Prefix:
First Name:MARIAM
Middle Name:MAHER KANDAS
Last Name:MICHAEL
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 1:628 E ALLEN AVE
Mailing Address - Street 2:
Mailing Address - City:SAN DIMAS
Mailing Address - State:CA
Mailing Address - Zip Code:91773-1525
Mailing Address - Country:US
Mailing Address - Phone:310-592-7149
Mailing Address - Fax:
Practice Address - Street 1:150 S GRAND AVE
Practice Address - Street 2:
Practice Address - City:GLENDORA
Practice Address - State:CA
Practice Address - Zip Code:91741-4217
Practice Address - Country:US
Practice Address - Phone:626-385-2442
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-07
Last Update Date:2018-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60768083183500000X
TX60837183500000X
CA77994183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist