Provider Demographics
NPI:1174101117
Name:MIRANDA, JEREMY
Entity type:Individual
Prefix:
First Name:JEREMY
Middle Name:
Last Name:MIRANDA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:318 MAGELLAN AVE UNIT A
Mailing Address - Street 2:
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96813-1804
Mailing Address - Country:US
Mailing Address - Phone:210-792-8826
Mailing Address - Fax:
Practice Address - Street 1:2500 CALIFORNIA PLZ
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68178-0133
Practice Address - Country:US
Practice Address - Phone:210-792-8826
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-31
Last Update Date:2021-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIT171012001183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist