Provider Demographics
NPI:1083896187
Name:MARION, GINA MARIE
Entity Type:Individual
Prefix:MRS
First Name:GINA
Middle Name:MARIE
Last Name:MARION
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:577 LARKFIELD RD
Mailing Address - Street 2:
Mailing Address - City:EAST NORTHPORT
Mailing Address - State:NY
Mailing Address - Zip Code:11731-4203
Mailing Address - Country:US
Mailing Address - Phone:631-368-3739
Mailing Address - Fax:631-368-0559
Practice Address - Street 1:577 LARKFIELD RD
Practice Address - Street 2:
Practice Address - City:EAST NORTHPORT
Practice Address - State:NY
Practice Address - Zip Code:11731-4203
Practice Address - Country:US
Practice Address - Phone:631-368-3739
Practice Address - Fax:631-368-0559
Is Sole Proprietor?:No
Enumeration Date:2007-11-29
Last Update Date:2007-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY049532183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00442219Medicaid