Provider Demographics
NPI:1609912229
Name:MARIANO PRIME LIMITED LIABILITY
Entity Type:Organization
Organization Name:MARIANO PRIME LIMITED LIABILITY
Other - Org Name:MEGA DRUG
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ARTHUR
Authorized Official - Middle Name:
Authorized Official - Last Name:MARIANO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:671-646-0020
Mailing Address - Street 1:255 FARENHOLT AVE
Mailing Address - Street 2:
Mailing Address - City:TAMUNING
Mailing Address - State:GU
Mailing Address - Zip Code:96913-3209
Mailing Address - Country:US
Mailing Address - Phone:671-646-5355
Mailing Address - Fax:671-646-5333
Practice Address - Street 1:255 FARENHOLT AVE
Practice Address - Street 2:
Practice Address - City:TAMUNING
Practice Address - State:GU
Practice Address - Zip Code:96913-3209
Practice Address - Country:US
Practice Address - Phone:671-646-5355
Practice Address - Fax:671-646-5333
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-30
Last Update Date:2016-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
GUPCY0353336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2112123OtherPK
GU650Medicaid