Provider Demographics
NPI:1508125246
Name:MARINER ADVANCED PHARMACY CORP
Entity Type:Organization
Organization Name:MARINER ADVANCED PHARMACY CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST-IN-CHARGE
Authorized Official - Prefix:DR
Authorized Official - First Name:HENRY
Authorized Official - Middle Name:
Authorized Official - Last Name:TRUONG
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:650-312-1342
Mailing Address - Street 1:43 E 3RD AVE
Mailing Address - Street 2:
Mailing Address - City:SAN MATEO
Mailing Address - State:CA
Mailing Address - Zip Code:94401-4010
Mailing Address - Country:US
Mailing Address - Phone:650-312-1342
Mailing Address - Fax:888-395-9798
Practice Address - Street 1:43 E 3RD AVE
Practice Address - Street 2:
Practice Address - City:SAN MATEO
Practice Address - State:CA
Practice Address - Zip Code:94401-4010
Practice Address - Country:US
Practice Address - Phone:650-312-1342
Practice Address - Fax:888-395-9798
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-15
Last Update Date:2016-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA100775251F00000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No251F00000XAgenciesHome Infusion