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:PSC 76 BOX 7182
Mailing Address - Street 2:
Mailing Address - City:APO
Mailing Address - State:AP
Mailing Address - Zip Code:96319-0072
Mailing Address - Country:US
Mailing Address - Phone:210-792-8826
Mailing Address - Fax:
Practice Address - Street 1:35TH MEDICAL GROUP
Practice Address - Street 2:BLDG 99, UNIT 5024
Practice Address - City:APO
Practice Address - State:AP
Practice Address - Zip Code:96319-5024
Practice Address - Country:US
Practice Address - Phone:315-226-6607
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-31
Last Update Date:2025-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIT171012001183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist