Healthcare Provider Details

I. General information

NPI: 1386471894
Provider Name (Legal Business Name): MARILU LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/18/2024
Last Update Date: 09/18/2024
Certification Date: 09/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

125 BATTLEFIELD CROSSING CT
RINGGOLD GA
30736-5176
US

IV. Provider business mailing address

578 CLASSIC TRL
RINGGOLD GA
30736-5895
US

V. Phone/Fax

Practice location:
  • Phone: 706-841-0540
  • Fax:
Mailing address:
  • Phone: 423-718-8521
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: DUSTIN BEARD
Title or Position: OWNER
Credential:
Phone: 423-718-8521