Provider Demographics
NPI:1942871876
Name:MITTA, MALLA (RPH)
Entity Type:Individual
Prefix:MR
First Name:MALLA
Middle Name:
Last Name:MITTA
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1524 10TH ST
Mailing Address - Street 2:
Mailing Address - City:PORT HURON
Mailing Address - State:MI
Mailing Address - Zip Code:48060-5815
Mailing Address - Country:US
Mailing Address - Phone:810-982-3100
Mailing Address - Fax:810-982-3106
Practice Address - Street 1:1524 10TH ST
Practice Address - Street 2:
Practice Address - City:PORT HURON
Practice Address - State:MI
Practice Address - Zip Code:48060-5815
Practice Address - Country:US
Practice Address - Phone:810-982-3100
Practice Address - Fax:810-982-3106
Is Sole Proprietor?:No
Enumeration Date:2021-07-01
Last Update Date:2021-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302038531183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist