Provider Demographics
NPI:1215076260
Name:MIKU PHARMACY INC
Entity type:Organization
Organization Name:MIKU PHARMACY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:AMANDA
Authorized Official - Middle Name:
Authorized Official - Last Name:TA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:949-582-3633
Mailing Address - Street 1:26902 OSO PKWY
Mailing Address - Street 2:STE 160
Mailing Address - City:MISSION VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92691-5801
Mailing Address - Country:US
Mailing Address - Phone:949-582-3633
Mailing Address - Fax:949-582-8264
Practice Address - Street 1:26902 OSO PKWY
Practice Address - Street 2:STE 160
Practice Address - City:MISSION VIEJO
Practice Address - State:CA
Practice Address - Zip Code:92691-5801
Practice Address - Country:US
Practice Address - Phone:949-582-3633
Practice Address - Fax:949-582-8264
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-06
Last Update Date:2021-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPHY536713336C0003X, 3336C0003X
3336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACB259629OtherMASS IMMUNIZATION ROSTER BILLER - NORIDIAN
CA1215076260Medicaid
CAPHA41998Medicaid
0572695OtherOTHER ID NUMBER-COMMERCIAL NUMBER