Provider Demographics
NPI:1164851978
Name:STREET, MARA
Entity Type:Individual
Prefix:
First Name:MARA
Middle Name:
Last Name:STREET
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MARA
Other - Middle Name:
Other - Last Name:WILLIAMS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RPH
Mailing Address - Street 1:1601 MARKET PLACE DR
Mailing Address - Street 2:
Mailing Address - City:GREAT FALLS
Mailing Address - State:MT
Mailing Address - Zip Code:59404-3481
Mailing Address - Country:US
Mailing Address - Phone:406-771-0475
Mailing Address - Fax:406-771-1425
Practice Address - Street 1:1601 MARKET PLACE DR
Practice Address - Street 2:
Practice Address - City:GREAT FALLS
Practice Address - State:MT
Practice Address - Zip Code:59404-3481
Practice Address - Country:US
Practice Address - Phone:406-771-0475
Practice Address - Fax:406-771-1425
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-02
Last Update Date:2013-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT3560183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist