Provider Demographics
NPI:1477853463
Name:SOURIAL, MARIETTE (PHARMD)
Entity Type:Individual
Prefix:MISS
First Name:MARIETTE
Middle Name:
Last Name:SOURIAL
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 1:109 MAPLE AVE E APT 2
Mailing Address - Street 2:
Mailing Address - City:MORA
Mailing Address - State:MN
Mailing Address - Zip Code:55051-1309
Mailing Address - Country:US
Mailing Address - Phone:518-894-8564
Mailing Address - Fax:
Practice Address - Street 1:301 HIGHWAY 65 S
Practice Address - Street 2:
Practice Address - City:MORA
Practice Address - State:MN
Practice Address - Zip Code:55051-1899
Practice Address - Country:US
Practice Address - Phone:320-225-3597
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-10-25
Last Update Date:2010-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN120221183500000X, 1835P1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
No1835P1200XPharmacy Service ProvidersPharmacistPharmacotherapy