Provider Demographics
NPI:1285789248
Name:MICHELLE MINE NA
Entity type:Organization
Organization Name:MICHELLE MINE NA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST & OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:MINE
Authorized Official - Last Name:NA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:213-382-0700
Mailing Address - Street 1:2528 W OLYMPIC BLVD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90006-2922
Mailing Address - Country:US
Mailing Address - Phone:213-382-0700
Mailing Address - Fax:213-480-1442
Practice Address - Street 1:2528 W OLYMPIC BLVD
Practice Address - Street 2:SUITE 102
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90006-2922
Practice Address - Country:US
Practice Address - Phone:213-382-0700
Practice Address - Fax:213-480-1442
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-23
Last Update Date:2022-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPHY431053336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0571667OtherNCPDP
CAPHA431050Medicaid
CA0571667OtherNCPDP