Individual
MIRIAM FOMEN FANGA
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Contact information
Practice address
4895 BOULDER HWY # 100, LAS VEGAS, NV 89121-3086
(702) 898-5264
Mailing address
2180 E WARM SPRINGS RD UNIT 2163, LAS VEGAS, NV 89119-0449
(240) 462-1809
Taxonomy
Speciality
Code
Description
License number
State
3336C0003X
Community/Retail Pharmacy
Primary
19831
NV
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
19831
PHARMACIST
NV
Enumeration date
04/08/2018
Last updated
06/16/2018
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