Healthcare Provider Details

I. General information

NPI: 1255680914
Provider Name (Legal Business Name): MARIANO PRIME LIMITED LIABILITY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/10/2012
Last Update Date: 10/11/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2042 ARMY DR
DEDEDO GU
96929-6516
US

IV. Provider business mailing address

2042 ARMY DR
DEDEDO GU
96929-6516
US

V. Phone/Fax

Practice location:
  • Phone: 671-646-5355
  • Fax: 671-646-5333
Mailing address:
  • Phone: 671-646-5355
  • Fax: 671-646-5333

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberPCY055
License Number StateGU

VIII. Authorized Official

Name: ARTHUR MARIANO
Title or Position: R.PH. / PRESIDENT
Credential:
Phone: 671-646-5355