Provider Demographics
NPI:1003980111
Name:MARISSA FOOD MART
Entity Type:Organization
Organization Name:MARISSA FOOD MART
Other - Org Name:DBA MARISSA DISCOUNT PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SECRETARY OF CORP.
Authorized Official - Prefix:MRS
Authorized Official - First Name:GAIL
Authorized Official - Middle Name:
Authorized Official - Last Name:LASKOWSKI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-295-2317
Mailing Address - Street 1:700 E. LYONS ST.
Mailing Address - Street 2:
Mailing Address - City:MARISSA
Mailing Address - State:IL
Mailing Address - Zip Code:62257
Mailing Address - Country:US
Mailing Address - Phone:618-295-2317
Mailing Address - Fax:618-295-2318
Practice Address - Street 1:700 E. LYONS ST.
Practice Address - Street 2:
Practice Address - City:MARISSA
Practice Address - State:IL
Practice Address - Zip Code:62257
Practice Address - Country:US
Practice Address - Phone:618-295-2317
Practice Address - Fax:618-295-2318
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MARISSA FOOD MART INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-11-20
Last Update Date:2015-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL054.009766333600000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL054009766OtherLICENSE