Healthcare Provider Details

I. General information

NPI: 1790806602
Provider Name (Legal Business Name): MARVICH ENTERPRISES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/02/2007
Last Update Date: 03/27/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19851 HARTMANN ROAD SUITE C
HIDDEN VALLEY LAKE CA
95467
US

IV. Provider business mailing address

19851 HARTMANN ROAD SUITE C
HIDDEN VALLEY LAKE CA
95467
US

V. Phone/Fax

Practice location:
  • Phone: 707-987-3995
  • Fax: 707-987-3120
Mailing address:
  • Phone: 707-987-3995
  • Fax: 707-987-3120

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberPHY45680
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: MICHAEL MARAVICH
Title or Position: MANAGING MEMBER
Credential: PHARM. D.
Phone: 707-900-1524