Provider Demographics
NPI:1619470499
Name:MOURAD, MARIANA
Entity Type:Individual
Prefix:
First Name:MARIANA
Middle Name:
Last Name:MOURAD
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 1:6325 TULIP DR
Mailing Address - Street 2:
Mailing Address - City:BEAUMONT
Mailing Address - State:TX
Mailing Address - Zip Code:77706-5533
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6325 TULIP DR
Practice Address - Street 2:
Practice Address - City:BEAUMONT
Practice Address - State:TX
Practice Address - Zip Code:77706-5533
Practice Address - Country:US
Practice Address - Phone:484-794-9013
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-17
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX56580183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist