Provider Demographics
NPI:1003408550
Name:MOUSSA, MARIANNE LENA (PHARMD)
Entity Type:Individual
Prefix:
First Name:MARIANNE
Middle Name:LENA
Last Name:MOUSSA
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5460 CONCORD BLVD APT B5
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:CA
Mailing Address - Zip Code:94521-2412
Mailing Address - Country:US
Mailing Address - Phone:925-876-4145
Mailing Address - Fax:
Practice Address - Street 1:5460 CONCORD BLVD APT B5
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:CA
Practice Address - Zip Code:94521-2412
Practice Address - Country:US
Practice Address - Phone:925-876-4145
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-05
Last Update Date:2021-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA82211183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist