Basic Information
| Provider Information | |||||||||
| NPI: | 1720409816 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MILLENNIUM MEDS MANAGEMENT LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 29211 | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850389211 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6022736770 | ||||||||
| FaxNumber: | 6028890483 | ||||||||
| Practice Location | |||||||||
| Address1: | 5208 WINDJAMMER RD | ||||||||
| Address2: | |||||||||
| City: | PLANO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750934023 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8004776770 | ||||||||
| FaxNumber: | 6028890483 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/17/2013 | ||||||||
| LastUpdateDate: | 12/17/2013 | ||||||||
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| AuthorizedOfficialLastName: | WINES | ||||||||
| AuthorizedOfficialFirstName: | MARK | ||||||||
| AuthorizedOfficialMiddleName: | W | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 8004776770 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332900000X | Y | Suppliers | Non-Pharmacy Dispensing Site |
No ID Information.