Provider Demographics
NPI:1083218697
Name:ROBERTO, MARISA (PHARM D)
Entity Type:Individual
Prefix:
First Name:MARISA
Middle Name:
Last Name:ROBERTO
Suffix:
Gender:F
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 POINTE DR
Mailing Address - Street 2:
Mailing Address - City:GANSEVOORT
Mailing Address - State:NY
Mailing Address - Zip Code:12831-1089
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:653 ROUTE 9
Practice Address - Street 2:
Practice Address - City:GANSEVOORT
Practice Address - State:NY
Practice Address - Zip Code:12831-1692
Practice Address - Country:US
Practice Address - Phone:518-584-4021
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-24
Last Update Date:2020-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY061050183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist