Provider Demographics
NPI:1366129322
Name:MIXLAB, INC.
Entity type:Organization
Organization Name:MIXLAB, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF PHARMACY OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:VINNIE
Authorized Official - Middle Name:
Authorized Official - Last Name:DAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:888-901-4480
Mailing Address - Street 1:3880 N 28TH TER
Mailing Address - Street 2:
Mailing Address - City:HOLLYWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:33020-1118
Mailing Address - Country:US
Mailing Address - Phone:888-901-4480
Mailing Address - Fax:212-267-0892
Practice Address - Street 1:3880 N 28TH TER
Practice Address - Street 2:
Practice Address - City:HOLLYWOOD
Practice Address - State:FL
Practice Address - Zip Code:33020-1118
Practice Address - Country:US
Practice Address - Phone:888-901-4480
Practice Address - Fax:212-267-0892
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-06-30
Last Update Date:2023-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy