Provider Demographics
NPI:1396038386
Name:NISPEROS, MARIETA GAMUTAN
Entity Type:Individual
Prefix:
First Name:MARIETA
Middle Name:GAMUTAN
Last Name:NISPEROS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MARIETA
Other - Middle Name:GAMUTAN
Other - Last Name:AARON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:93 N PLAINS RD
Mailing Address - Street 2:
Mailing Address - City:THE PLAINS
Mailing Address - State:OH
Mailing Address - Zip Code:45780-1016
Mailing Address - Country:US
Mailing Address - Phone:740-797-2546
Mailing Address - Fax:
Practice Address - Street 1:93 N PLAINS RD
Practice Address - Street 2:
Practice Address - City:THE PLAINS
Practice Address - State:OH
Practice Address - Zip Code:45780-1016
Practice Address - Country:US
Practice Address - Phone:740-797-2546
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-05-24
Last Update Date:2011-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03129188183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist