Provider Demographics
NPI:1225893308
Name:ZETRENNE, MARCILLIN
Entity Type:Individual
Prefix:
First Name:MARCILLIN
Middle Name:
Last Name:ZETRENNE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1450 NW 47TH AVE
Mailing Address - Street 2:
Mailing Address - City:COCONUT CREEK
Mailing Address - State:FL
Mailing Address - Zip Code:33063-3947
Mailing Address - Country:US
Mailing Address - Phone:954-903-8196
Mailing Address - Fax:
Practice Address - Street 1:2204 S 5TH ST
Practice Address - Street 2:
Practice Address - City:LEESVILLE
Practice Address - State:LA
Practice Address - Zip Code:71446-5327
Practice Address - Country:US
Practice Address - Phone:337-238-9305
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-16
Last Update Date:2024-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAPST.025173183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist