=====================================================
General NPI Number Information
=====================================================
NPI Number | 1548842214
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MARYMOOR PHARMACY, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/22/2021
-----------------------------------------------------
Last Update Date | 09/29/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2533 152ND AVE NE STE 14JK
-----------------------------------------------------
City | REDMOND
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98052-5550
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 425-968-8492
-----------------------------------------------------
Fax | 425-968-8534
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3121 DIABLO AVE
-----------------------------------------------------
City | HAYWARD
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94545
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 650-353-5495
-----------------------------------------------------
Fax | 650-435-5932
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER
-----------------------------------------------------
Name | SIDDHARTH VISWANATHAN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 650-353-5495
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------