Provider Demographics
NPI:1124268750
Name:GOKHALE, MIRA (RPH)
Entity type:Individual
Prefix:MS
First Name:MIRA
Middle Name:
Last Name:GOKHALE
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7332 BLAKE DR
Mailing Address - Street 2:
Mailing Address - City:BAY CITY
Mailing Address - State:MI
Mailing Address - Zip Code:48706-8325
Mailing Address - Country:US
Mailing Address - Phone:989-326-0296
Mailing Address - Fax:
Practice Address - Street 1:1490 W CENTER RD
Practice Address - Street 2:
Practice Address - City:ESSEXVILLE
Practice Address - State:MI
Practice Address - Zip Code:48732-2112
Practice Address - Country:US
Practice Address - Phone:989-892-1565
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-02-22
Last Update Date:2009-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302036073183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1760591200Medicaid