Provider Demographics
NPI:1508120890
Name:PRETORIUS, MARISEL
Entity Type:Individual
Prefix:MRS
First Name:MARISEL
Middle Name:
Last Name:PRETORIUS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3322 132ND ST SE
Mailing Address - Street 2:
Mailing Address - City:MILL CREEK
Mailing Address - State:WA
Mailing Address - Zip Code:98012-5654
Mailing Address - Country:US
Mailing Address - Phone:425-338-1891
Mailing Address - Fax:425-338-2863
Practice Address - Street 1:3322 132ND ST SE
Practice Address - Street 2:
Practice Address - City:MILL CREEK
Practice Address - State:WA
Practice Address - Zip Code:98012-5654
Practice Address - Country:US
Practice Address - Phone:425-338-1891
Practice Address - Fax:425-338-2863
Is Sole Proprietor?:No
Enumeration Date:2012-07-01
Last Update Date:2012-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH 00051567183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist