Provider Demographics
NPI:1194600833
Name:VINCENT, JAVAN MIRUKA
Entity type:Individual
Prefix:
First Name:JAVAN
Middle Name:MIRUKA
Last Name:VINCENT
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 1:4110 WILLIAMS WAY BLVD
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:TX
Mailing Address - Zip Code:77469-2502
Mailing Address - Country:US
Mailing Address - Phone:281-239-7071
Mailing Address - Fax:
Practice Address - Street 1:4110 WILLIAMS WAY BLVD
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:TX
Practice Address - Zip Code:77469-2502
Practice Address - Country:US
Practice Address - Phone:281-239-7071
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-08-11
Last Update Date:2025-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX382165183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician