Provider Demographics
NPI:1033564307
Name:RYDBOM, MARIANNE (RPH)
Entity Type:Individual
Prefix:
First Name:MARIANNE
Middle Name:
Last Name:RYDBOM
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 397
Mailing Address - Street 2:
Mailing Address - City:COALPORT
Mailing Address - State:PA
Mailing Address - Zip Code:16627-0397
Mailing Address - Country:US
Mailing Address - Phone:814-672-5387
Mailing Address - Fax:814-672-3039
Practice Address - Street 1:1564 MAIN STREET
Practice Address - Street 2:
Practice Address - City:COALPORT
Practice Address - State:PA
Practice Address - Zip Code:16627
Practice Address - Country:US
Practice Address - Phone:814-672-5387
Practice Address - Fax:814-672-3039
Is Sole Proprietor?:No
Enumeration Date:2016-04-25
Last Update Date:2016-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARP038329L183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist