Provider Demographics
NPI:1063919991
Name:FANGA, MIRIAM FOMEN
Entity type:Individual
Prefix:
First Name:MIRIAM
Middle Name:FOMEN
Last Name:FANGA
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 1:2180 E WARM SPRINGS RD UNIT 2163
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89119-0449
Mailing Address - Country:US
Mailing Address - Phone:240-462-1809
Mailing Address - Fax:
Practice Address - Street 1:4895 BOULDER HWY # 100
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89121-3086
Practice Address - Country:US
Practice Address - Phone:702-898-5264
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-08
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV198313336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV19831OtherPHARMACIST