Provider Demographics
NPI:1700874591
Name:MIRAVIDA LIVING
Entity Type:Organization
Organization Name:MIRAVIDA LIVING
Other - Org Name:LHO PHARMACY LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF PHARM SERVICES
Authorized Official - Prefix:
Authorized Official - First Name:BARRY
Authorized Official - Middle Name:
Authorized Official - Last Name:BREWER
Authorized Official - Suffix:
Authorized Official - Credentials:BS-PHARMACY
Authorized Official - Phone:920-966-1345
Mailing Address - Street 1:225 N EAGLE ST
Mailing Address - Street 2:
Mailing Address - City:OSHKOSH
Mailing Address - State:WI
Mailing Address - Zip Code:54902-4125
Mailing Address - Country:US
Mailing Address - Phone:920-966-1345
Mailing Address - Fax:920-966-1285
Practice Address - Street 1:225 N EAGLE ST
Practice Address - Street 2:
Practice Address - City:OSHKOSH
Practice Address - State:WI
Practice Address - Zip Code:54902-4125
Practice Address - Country:US
Practice Address - Phone:920-966-1345
Practice Address - Fax:920-966-1285
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-06
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0003X
WI8273423336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No333600000XSuppliersPharmacyGroup - Single Specialty
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2110060OtherPK
WI33267400Medicaid