Provider Demographics
NPI:1558906933
Name:BASILY, MARINA (RPH)
Entity Type:Individual
Prefix:
First Name:MARINA
Middle Name:
Last Name:BASILY
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19121 112TH AVE NE APT 636
Mailing Address - Street 2:
Mailing Address - City:BOTHELL
Mailing Address - State:WA
Mailing Address - Zip Code:98011-0042
Mailing Address - Country:US
Mailing Address - Phone:678-252-7511
Mailing Address - Fax:
Practice Address - Street 1:19121 112TH AVE NE APT 636
Practice Address - Street 2:
Practice Address - City:BOTHELL
Practice Address - State:WA
Practice Address - Zip Code:98011-0042
Practice Address - Country:US
Practice Address - Phone:678-252-7511
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-09
Last Update Date:2019-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60925907183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist