Provider Demographics
NPI:1477000818
Name:DUTRA, MARISSA MARLENE (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:MARISSA
Middle Name:MARLENE
Last Name:DUTRA
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 1:1330 GOLDFISH FARM RD SE
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:OR
Mailing Address - Zip Code:97322-5154
Mailing Address - Country:US
Mailing Address - Phone:541-971-4062
Mailing Address - Fax:541-971-4053
Practice Address - Street 1:1330 GOLDFISH FARM RD SE
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:OR
Practice Address - Zip Code:97322-5154
Practice Address - Country:US
Practice Address - Phone:541-971-4062
Practice Address - Fax:541-971-4053
Is Sole Proprietor?:No
Enumeration Date:2016-09-01
Last Update Date:2022-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR15560183500000X
OR00155601835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
No183500000XPharmacy Service ProvidersPharmacist