Provider Demographics
NPI:1093306953
Name:SANTIAGO, MARIEL CAMILLE (PHARMD)
Entity Type:Individual
Prefix:
First Name:MARIEL CAMILLE
Middle Name:
Last Name:SANTIAGO
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3015 DIVISION ST APT 215
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90065-2069
Mailing Address - Country:US
Mailing Address - Phone:626-393-2031
Mailing Address - Fax:
Practice Address - Street 1:1701 S WESTERN AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90006-5803
Practice Address - Country:US
Practice Address - Phone:323-731-9247
Practice Address - Fax:323-731-0893
Is Sole Proprietor?:No
Enumeration Date:2021-02-02
Last Update Date:2021-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA83980183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist