Provider Demographics
NPI:1932925633
Name:MIXLAB WI, LLC
Entity type:Organization
Organization Name:MIXLAB WI, LLC
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:PHARMD, MS
Authorized Official - Phone:347-610-9820
Mailing Address - Street 1:407 W SILVER SPRING DR
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53217-5048
Mailing Address - Country:US
Mailing Address - Phone:888-901-4480
Mailing Address - Fax:212-967-0892
Practice Address - Street 1:407 W SILVER SPRING DR
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53217-5048
Practice Address - Country:US
Practice Address - Phone:888-901-4480
Practice Address - Fax:212-967-0892
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MIXLAB, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2024-11-26
Last Update Date:2024-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy