Provider Demographics
NPI:1922375476
Name:BASRAI, MIRANDA LIU (PHARM D)
Entity Type:Individual
Prefix:
First Name:MIRANDA
Middle Name:LIU
Last Name:BASRAI
Suffix:
Gender:F
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 1:43605 BRYANT ST
Mailing Address - Street 2:
Mailing Address - City:FREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:94539-5809
Mailing Address - Country:US
Mailing Address - Phone:510-366-9218
Mailing Address - Fax:
Practice Address - Street 1:43605 BRYANT ST
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:CA
Practice Address - Zip Code:94539-5809
Practice Address - Country:US
Practice Address - Phone:510-366-9218
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-29
Last Update Date:2011-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA39551183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist