Healthcare Provider Details

I. General information

NPI: 1083896187
Provider Name (Legal Business Name): MRS. GINA MARIE MARION
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/29/2007
Last Update Date: 11/29/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

577 LARKFIELD RD
EAST NORTHPORT NY
11731-4203
US

IV. Provider business mailing address

577 LARKFIELD RD
EAST NORTHPORT NY
11731-4203
US

V. Phone/Fax

Practice location:
  • Phone: 631-368-3739
  • Fax: 631-368-0559
Mailing address:
  • Phone: 631-368-3739
  • Fax: 631-368-0559

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number049532
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: