Healthcare Provider Details

I. General information

NPI: 1407407737
Provider Name (Legal Business Name): MARIANO PRIME LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/27/2019
Last Update Date: 09/27/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

548 S MARINE CORPS DR
TAMUNING GU
96913-3539
US

IV. Provider business mailing address

255 FARENHOLT AVE
TAMUNING GU
96913-3209
US

V. Phone/Fax

Practice location:
  • Phone: 671-969-5900
  • Fax: 671-969-2800
Mailing address:
  • Phone: 671-646-5355
  • Fax: 671-646-5333

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0002X
TaxonomyClinic Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: ARTHUR SURLA MARIANO
Title or Position: PRESIDENT
Credential:
Phone: 671-646-5355