Provider Demographics
NPI:1306241955
Name:O'BRIEN, MIRANDA
Entity type:Individual
Prefix:DR
First Name:MIRANDA
Middle Name:
Last Name:O'BRIEN
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 1:36252 LIGHTHOUSE RD
Mailing Address - Street 2:
Mailing Address - City:SELBYVILLE
Mailing Address - State:DE
Mailing Address - Zip Code:19975-9120
Mailing Address - Country:US
Mailing Address - Phone:302-436-6411
Mailing Address - Fax:
Practice Address - Street 1:36252 LIGHTHOUSE RD
Practice Address - Street 2:
Practice Address - City:SELBYVILLE
Practice Address - State:DE
Practice Address - Zip Code:19975-9120
Practice Address - Country:US
Practice Address - Phone:302-436-6411
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-24
Last Update Date:2014-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEA1-0004657183500000X
MD17485183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist