Provider Demographics
NPI:1518577741
Name:BLACK PANDA LLC
Entity type:Organization
Organization Name:BLACK PANDA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:BARBARA
Authorized Official - Middle Name:
Authorized Official - Last Name:DEINET
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:702-219-6173
Mailing Address - Street 1:6280 S VALLEY VIEW BLVD STE 734
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89118-6833
Mailing Address - Country:US
Mailing Address - Phone:702-219-6173
Mailing Address - Fax:
Practice Address - Street 1:2507 S STATE ST
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84115-3109
Practice Address - Country:US
Practice Address - Phone:855-558-2382
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-08-03
Last Update Date:2020-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy