Provider Demographics
NPI:1811546419
Name:MESA, MAYLEN
Entity Type:Individual
Prefix:
First Name:MAYLEN
Middle Name:
Last Name:MESA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11340 SW 45TH ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33165-5542
Mailing Address - Country:US
Mailing Address - Phone:305-263-0194
Mailing Address - Fax:
Practice Address - Street 1:14190 SW 26TH ST
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33175-7257
Practice Address - Country:US
Practice Address - Phone:305-559-7745
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-05
Last Update Date:2019-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS59852183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist