Provider Demographics
NPI:1073140026
Name:MARINA BAY PHARMACY, LLC
Entity Type:Organization
Organization Name:MARINA BAY PHARMACY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CORPORATE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:JOHANNA
Authorized Official - Middle Name:
Authorized Official - Last Name:LAZANO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:832-932-3696
Mailing Address - Street 1:1416 E MAIN ST STE C
Mailing Address - Street 2:
Mailing Address - City:LEAGUE CITY
Mailing Address - State:TX
Mailing Address - Zip Code:77573-4153
Mailing Address - Country:US
Mailing Address - Phone:832-932-3696
Mailing Address - Fax:832-932-3697
Practice Address - Street 1:1416 E MAIN ST STE C
Practice Address - Street 2:
Practice Address - City:LEAGUE CITY
Practice Address - State:TX
Practice Address - Zip Code:77573-4153
Practice Address - Country:US
Practice Address - Phone:832-932-3696
Practice Address - Fax:832-932-3697
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-03-26
Last Update Date:2021-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy