Provider Demographics
NPI:1619525201
Name:BASALY, MARIAN (RPH)
Entity Type:Individual
Prefix:
First Name:MARIAN
Middle Name:
Last Name:BASALY
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 1:527 OLD BRIDGE TPKE UNIT 3315
Mailing Address - Street 2:
Mailing Address - City:EAST BRUNSWICK
Mailing Address - State:NJ
Mailing Address - Zip Code:08816-1946
Mailing Address - Country:US
Mailing Address - Phone:732-718-9395
Mailing Address - Fax:
Practice Address - Street 1:353 US-202 #206
Practice Address - Street 2:
Practice Address - City:BRIDGEWATER TOWNSHIP
Practice Address - State:NJ
Practice Address - Zip Code:08807
Practice Address - Country:US
Practice Address - Phone:908-722-8123
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-28
Last Update Date:2019-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RI03968900183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist