=====================================================
General NPI Number Information
=====================================================
NPI Number | 1437532017
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARBEN MOPERA PHARM.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/01/2015
-----------------------------------------------------
Last Update Date | 07/01/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1615 E BASELINE RD
-----------------------------------------------------
City | PHOENIX
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85042-6801
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 602-276-6001
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2022 N NEVADA ST APT 2195
-----------------------------------------------------
City | CHANDLER
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85225-0954
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-246-7672
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | S021216
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------