Provider Demographics
NPI:1801231428
Name:MDM PHARMACY SERVICES LLC
Entity Type:Organization
Organization Name:MDM PHARMACY SERVICES LLC
Other - Org Name:NEW PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST IN CHARGE / OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MAHER
Authorized Official - Middle Name:
Authorized Official - Last Name:MICHAIL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:760-851-8120
Mailing Address - Street 1:57725 29 PALMS HWY
Mailing Address - Street 2:SUITE 209
Mailing Address - City:YUCCA VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92284-3044
Mailing Address - Country:US
Mailing Address - Phone:760-228-1600
Mailing Address - Fax:
Practice Address - Street 1:57725 29 PALMS HWY STE 209
Practice Address - Street 2:
Practice Address - City:YUCCA VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92284-3044
Practice Address - Country:US
Practice Address - Phone:760-228-1600
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-09
Last Update Date:2014-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0004X, 3336H0001X
CA514393336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336H0001XSuppliersPharmacyHome Infusion Therapy Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2140258OtherPK
2140258OtherPK