MEDICARE: DR. MARIAH VASQUEZ PHARMD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1835P0018X	Pharmacist Clinician (PhC)/ Clinical Pharmacy Specialist	26027429A	IN

General Provider Information

NPI Number	:	1306465570
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARIAH VASQUEZ PHARMD

Provider Business Mailing Address
First Line	:	110 E CREIGHTON AVE
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46803-3344
Country	:	US
Telephone Number	:	260-456-1841
Fax Number	:

Provider Business Practice Location Address
First Line	:	110 E CREIGHTON AVE
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46803-3344
Country	:	US
Telephone Number	:	260-456-1841
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/08/2020
Last Update Date	:	04/08/2020

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