Healthcare Provider Details

I. General information

NPI: 1053523100
Provider Name (Legal Business Name): FARMACIA DE MARIANAS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/03/2007
Last Update Date: 07/06/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

543 CHALAN GUMAYUOS
TAMUNING GU
96913
US

IV. Provider business mailing address

PO BOX 8718
TAMUNING GU
96932
US

V. Phone/Fax

Practice location:
  • Phone: 671-646-9696
  • Fax: 671-649-6601
Mailing address:
  • Phone: 671-646-9696
  • Fax: 671-649-6601

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License NumberPCY004
License Number StateGU

VIII. Authorized Official

Name: MRS. MARIA LUZ BALUYOT GUZMAN
Title or Position: OWNER MANAGER
Credential: REGISTERED PHARMACIS
Phone: 671-646-9696